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8801. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72559/psn-pdf
      December 09, 2020 - The Life and Death of Elizabeth Dixon: A Catalyst for Change. December 9, 2020 Kirkup B. London, England: Crown Copyright; 2020. ISBN 9781528622714. https://psnet.ahrq.gov/issue/life-and-death-elizabeth-dixon-catalyst-change Missed diagnosis of a dangerous condition in utero, treatment errors, lack of respons…

8802. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44327/psn-pdf
      August 26, 2015 - Safely Home: What Happens When People Leave Hospital Care Settings? August 26, 2015 London, UK: Healthwatch England; July 2015. https://psnet.ahrq.gov/issue/safely-home-what-happens-when-people-leave-hospital-care-settings Discharges are vulnerable periods for patients, often due to miscommunication, delays, and l…

8803. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34100/psn-pdf
      February 09, 2011 - Safety of patients isolated for infection control. February 9, 2011 Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infection control. JAMA. 2003;290(14):1899-1905. https://psnet.ahrq.gov/issue/safety-patients-isolated-infection-control This study discovered that patients isolated for coloniza…

8804. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72534/psn-pdf
      December 02, 2020 - Patients' perceptions of safety in emergency medical services: an interview study. December 2, 2020 Venesoja A, Castrén M, Tella S, et al. Patients’ perceptions of safety in emergency medical services: an interview study. BMJ Open. 2020;10(10):e037488. doi:10.1136/bmjopen-2020-037488. https://psnet.ahrq.gov/issue/…

8805. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46516/psn-pdf
      December 16, 2017 - The business case for investing in physician well-being. December 16, 2017 Shanafelt TD, Goh J, Sinsky CA. The Business Case for Investing in Physician Well-being. JAMA Intern Med. 2017;177(12):1826-1832. doi:10.1001/jamainternmed.2017.4340. https://psnet.ahrq.gov/issue/business-case-investing-physician-well-being …

8806. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846451/psn-pdf
      March 22, 2023 - Reducing risks in complex care transitions in rural areas: a grounded theory. March 22, 2023 Winqvist I, Näppä U, Rönning H, et al. Reducing risks in complex care transitions in rural areas: a grounded theory. Int J Qual Stud Health Well-being. 2023;18(1):2185964. doi:10.1080/17482631.2023.2185964. https://psnet.…

8807. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837042/psn-pdf
      April 04, 2022 - Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management. April 4, 2022 Institute for Healthcare Improvement. https://psnet.ahrq.gov/issue/leadership-response-sentinel-event-respectful-effective-crisis-management Crisis management skills are valuable at both the organizational and clinical …

8808. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43505/psn-pdf
      April 25, 2016 - Hospitals often ignore policies on using qualified medical interpreters. April 25, 2016 Rice S. Language liabilities. To avoid errors, hospitals urged to use qualified interpreters for patients with limited English. Modern healthcare. 2014;44(35):16-8, 20. https://psnet.ahrq.gov/issue/hospitals-often-ignore-polici…

8809. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42991/psn-pdf
      March 12, 2014 - Medication errors in hospitalised children. March 12, 2014 Manias E, Kinney S, Cranswick N, et al. Medication errors in hospitalised children. J Paediatr Child Health. 2014;50(1):71-7. doi:10.1111/jpc.12412. https://psnet.ahrq.gov/issue/medication-errors-hospitalised-children Consistent with findings from prior st…

8810. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852806/psn-pdf
      February 24, 2025 - Covering Health: Patient Safety. February 24, 2025 Jaklevic MC. HealthJournalism.org. Columbia, MO: Association of Health Care Journalists; 2010-2025. https://psnet.ahrq.gov/issue/covering-health-patient-safety The role media plays in raising awareness of patient safety issues in a timely and appropriate…

8811. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60567/psn-pdf
      June 03, 2020 - Keeping Nursing Home Residents and Staff Safe in the Era of COVID-19. June 3, 2020 National Academy of Medicine. April-June 2020. https://psnet.ahrq.gov/issue/keeping-nursing-home-residents-and-staff-safe-era-covid-19 Nursing homes are care environments that are particularly challenged by the COVID-19 pandemic. Th…

8812. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48082/psn-pdf
      June 19, 2019 - Unintended discontinuation of medication following hospitalisation: a retrospective cohort study. June 19, 2019 Redmond P, McDowell R, Grimes TC, et al. Unintended discontinuation of medication following hospitalisation: a retrospective cohort study. BMJ Open. 2019;9(6):e024747. doi:10.1136/bmjopen-2018- 024747. …

8813. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41511/psn-pdf
      June 03, 2013 - A multicentre observational study to evaluate a new tool to assess emergency physicians' non-technical skills. June 3, 2013 Flowerdew L, Gaunt A, Spedding J, et al. A multicentre observational study to evaluate a new tool to assess emergency physicians' non-technical skills. Emerg Med J. 2013;30(6):437-43. doi:10.…

8814. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34770/psn-pdf
      April 17, 2017 - Clinical Risk Management. Enhancing Patient Safety. 2nd ed. April 17, 2017 Vincent CA, ed. London, UK: BMJ Books; 2001. ISBN: 9780727913920. https://psnet.ahrq.gov/issue/clinical-risk-management-enhancing-patient-safety-2nd-ed Vincent has updated his text on risk management, infusing it with concepts directly rela…

8815. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41873/psn-pdf
      November 28, 2012 - A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care. November 28, 2012 Chesluk BJ, Bernabeo E, Hess B, et al. A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care. Health Aff (Millwood). 2012;31(11):2485-2492. do…

8816. Action Planning for the SOPS™ Surveys Infographic (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/action-planning-webcast-graphic.pdf
      February 01, 2019 - Action Planning for the SOPS™ Surveys Infographic Action Planning for the SOPSTM  Surveys January 2019 Webcast Highlights AHRQ's Surveys on Patient Safety CultureTM(SOPS TM) Action Planning Tool guides survey users seeking to improve patient safety culture through the action planning process. The Action Plann…

8817. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/worksheet.docx
      May 01, 2017 - AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership AHRQ Safety Program for Perinatal Care Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership Purpose: To enhance communication and shared problem solving between clinic…

8818. Long-term Care Facilities | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/index.html
      September 01, 2021 - Long-term Care Facilities Resources for long-term care facilities Improving Patient Safety in Long-Term Care Facilities Detecting and promptly reporting changes in a nursing home resident's condition are critical for ensuring the resident's well-being and safety. Such changes may represent a patient s…

8819. National Action Alliance Webinar: Establishing Psychological Safety for Healthcare Workers | Agency for Healthcare Research and Quality
      www.ahrq.gov/action-alliance/webinars/psychological-safety.html
      March 01, 2025 - National Action Alliance Webinar: Establishing Psychological Safety for Healthcare Workers Creating and Maintaining a Culture of Safety Series (Session 1) This webinar was the first of a three-part series on Safety Culture in Healthcare. On February 18, 2025, experts shared how leadership rounding with staff …

8820. Technical Bundles Module | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/technical-bundles.html
      March 01, 2017 - Technical Bundles Module This module provides evidence-based recommendations, literature reviews, sample protocols, and other resources to help the team address the following topics: Daily Care Processes Early Mobility Low Tidal Volume Ventilation Overview of the AHRQ Safety Program for Mechanically…