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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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 …
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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-…
  8. Psn-Pdf (pdf file)

    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.…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. Psn-Pdf (pdf file)

    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…
  17. Psn-Pdf (pdf file)

    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.…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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 …