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psnet.ahrq.gov/node/43316/psn-pdf
July 02, 2014 - Optimizing transitions of care to reduce
rehospitalizations.
July 2, 2014
Li J, Young R, Williams M. Optimizing transitions of care to reduce rehospitalizations. Cleve Clin J Med.
2014;81(5):312-20. doi:10.3949/ccjm.81a.13106.
https://psnet.ahrq.gov/issue/optimizing-transitions-care-reduce-rehospitalizations
Care…
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psnet.ahrq.gov/node/73996/psn-pdf
October 29, 2021 - Patient, Medical, and Legal Perspectives of Unsafe Care.
October 20, 2021
Patient Safety Movement. October 29, 2021.
https://psnet.ahrq.gov/issue/patient-medical-and-legal-perspectives-unsafe-care
Effective response to medical harm involves a variety of perspectives that are aligned in purpose. This
webinar …
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psnet.ahrq.gov/node/859352/psn-pdf
December 20, 2023 - More hospitals move to confront medical errors head on.
December 20, 2023
Gorenstein D. Tradeoffs. November 16, 2023.
https://psnet.ahrq.gov/issue/more-hospitals-move-confront-medical-errors-head
Amid governmental guidance to improve safety, front-line perspectives remain an important source for
insight to make im…
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psnet.ahrq.gov/node/44090/psn-pdf
November 21, 2016 - Insensible losses: when the medical community forgets
the family.
November 21, 2016
Elias P. Insensible losses: when the medical community forgets the family. Health Aff (Millwood).
2015;34(4):707-710. doi:10.1377/hlthaff.2014.0536.
https://psnet.ahrq.gov/issue/insensible-losses-when-medical-community-forgets-fami…
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psnet.ahrq.gov/node/838084/psn-pdf
September 14, 2022 - Sixty seconds on . . . medical gaslighting.
September 14, 2022
Wise J. Sixty seconds on . . . medical gaslighting. BMJ. 2022;378:o1974. doi:10.1136/bmj.o1974.
https://psnet.ahrq.gov/issue/sixty-seconds-medical-gaslighting
Patients can be vulnerable to having concerns dismissed or being gaslighted as to their legiti…
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psnet.ahrq.gov/node/35339/psn-pdf
April 23, 2014 - Disclosing harmful medical errors to patients: a time for
professional action.
April 23, 2014
Gallagher TH, Levinson W. Disclosing Harmful Medical Errors to Patients. Arch Intern Med. 2005;165(16).
doi:10.1001/archinte.165.16.1819.
https://psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients-time-profes…
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psnet.ahrq.gov/node/37512/psn-pdf
February 06, 2008 - Risk factors in preventable adverse drug events in
pediatric outpatients.
February 6, 2008
Zandieh SO, Goldmann DA, Keohane C, et al. Risk factors in preventable adverse drug events in pediatric
outpatients. J Pediatr. 2008;152(2):225-31. doi:10.1016/j.jpeds.2007.09.054.
https://psnet.ahrq.gov/issue/risk-factors-…
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psnet.ahrq.gov/node/73223/psn-pdf
May 05, 2021 - Pandemic imperiled non-English speakers more than
others.
May 5, 2021
Bebinger M. WBUR and Kaiser Health News. April 27, 2021.
https://psnet.ahrq.gov/issue/pandemic-imperiled-non-english-speakers-more-others
Non-English-speaking patients experience barriers to safely navigating the American healthcare system.…
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psnet.ahrq.gov/node/73861/psn-pdf
September 22, 2021 - Bringing the clinical laboratory into the strategy to
advance diagnostic excellence.
September 22, 2021
Lubin IM, Astles J R, Shahangian S, et al. Bringing the clinical laboratory into the strategy to advance
diagnostic excellence. Diagnosis (Berl). 2021;8(3):281-294. doi:10.1515/dx-2020-0119.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/36198/psn-pdf
March 28, 2011 - Using human error theory to explore the supply of non-
prescription medicines from community pharmacies.
March 28, 2011
Watson MC, Bond CM, Johnston M, et al. Using human error theory to explore the supply of non-
prescription medicines from community pharmacies. Qual Saf Health Care. 2006;15(4):244-50.
https://ps…
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psnet.ahrq.gov/node/50568/psn-pdf
October 23, 2019 - Automation of the I-PASS tool to improve transitions of
care.
October 23, 2019
Skaret MM, Weaver TD, Humes RJ, et al. Automation of the I-PASS Tool to Improve Transitions of Care. J
Healthc Qual. 2019;41(5):274-280. doi:10.1097/JHQ.0000000000000174.
https://psnet.ahrq.gov/issue/automation-i-pass-tool-improve-trans…
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psnet.ahrq.gov/node/43566/psn-pdf
December 19, 2014 - Bedside shift reports: what does the evidence say?
December 19, 2014
Gregory S, Tan D, Tilrico M, et al. Bedside shift reports: what does the evidence say? J Nurs Adm.
2014;44(10):541-5. doi:10.1097/NNA.0000000000000115.
https://psnet.ahrq.gov/issue/bedside-shift-reports-what-does-evidence-say
Bedside shift report…
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psnet.ahrq.gov/node/45999/psn-pdf
March 29, 2017 - Two words can soothe patients who have been harmed:
we're sorry.
March 29, 2017
Boodman SG. Kaiser Health News. March 15, 2017.
https://psnet.ahrq.gov/issue/two-words-can-soothe-patients-who-have-been-harmed-were-sorry
This news article reports on two incidents involving medical errors—one demonstrating the tradit…
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psnet.ahrq.gov/node/43033/psn-pdf
March 12, 2014 - Current challenges and future perspectives for patient
safety in surgery.
March 12, 2014
Stahel PF, Mauffrey C, Butler N. Current challenges and future perspectives for patient safety in surgery.
Patient Saf Surg. 2014;8(1):9. doi:10.1186/1754-9493-8-9.
https://psnet.ahrq.gov/issue/current-challenges-and-future-pe…
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psnet.ahrq.gov/node/46508/psn-pdf
November 22, 2017 - The checklist: recognize limits, but harness its power.
November 22, 2017
Alspach JAG. The Checklist: Recognize Limits, but Harness Its Power. Crit Care Nurse. 2017;37(5):12-18.
doi:10.4037/ccn2017603.
https://psnet.ahrq.gov/issue/checklist-recognize-limits-harness-its-power
Checklists are used in various health c…
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psnet.ahrq.gov/node/856640/psn-pdf
November 29, 2023 - Research from webAIRS incident reporting system.
November 29, 2023
Anaesth Intensive Care. 2023;51(6):372-421.
https://psnet.ahrq.gov/issue/research-webairs-incident-reporting-system
Centralized de-identified reports of patient safety events serve a core purpose for learning and
improvement. This article collectio…
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psnet.ahrq.gov/node/41849/psn-pdf
December 05, 2012 - Improving care transitions: current practice and future
opportunities for pharmacists.
December 5, 2012
Pharmacy AC of C, Hume AL, Kirwin J, et al. Improving care transitions: current practice and future
opportunities for pharmacists. Pharmacotherapy. 2012;32(11):e326-37. doi:10.1002/phar.1215.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/50825/psn-pdf
January 22, 2020 - Investigation into Detection of Retained Vaginal Swabs
and Tampons Following Childbirth.
January 22, 2020
Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.
https://psnet.ahrq.gov/issue/investigation-detection-retained-vaginal-swabs-and-tampons-following-
childbirth
Maternal care during a…
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psnet.ahrq.gov/node/45837/psn-pdf
March 08, 2017 - Promoting civility in the OR: an ethical imperative.
March 8, 2017
Clark CM, Kenski D. Promoting Civility in the OR: An Ethical Imperative. AORN J. 2017;105(1):60-66.
doi:10.1016/j.aorn.2016.10.019.
https://psnet.ahrq.gov/issue/promoting-civility-or-ethical-imperative
The operating room is a complex environment th…
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psnet.ahrq.gov/node/861295/psn-pdf
January 24, 2024 - Investigators find hospital error caused mother’s death in
Brooklyn.
January 24, 2024
Goldstein J. New York Times. January 14, 2024.
https://psnet.ahrq.gov/issue/investigators-find-hospital-error-caused-mothers-death-brooklyn
Maternal safety is challenged in the Unites States and particularly for minorities. This …