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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837974/psn-pdf
    August 31, 2022 - Fostering a just culture in healthcare organizations: experiences in practice. August 31, 2022 van Baarle E, Hartman L, Rooijakkers S, et al. Fostering a just culture in healthcare organizations: experiences in practice. BMC Health Serv Res. 2022;22(1):1035. doi:10.1186/s12913-022-08418-z. https://psnet.ahrq.gov/i…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40132/psn-pdf
    May 25, 2011 - Information needs in operating room teams: what is right, what is wrong, and what is needed? May 25, 2011 Forrest D, Healey A, Shirafkan H, et al. Information needs in operating room teams: what is right, what is wrong, and what is needed? Surg Endosc. 2011;25(6):1913-20. doi:10.1007/s00464-010-1486-z. https://psn…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46449/psn-pdf
    September 27, 2017 - VA hospitals flooded with complaints about care. September 27, 2017 Estes A. Boston Globe. September 16, 2017. https://psnet.ahrq.gov/issue/va-hospitals-flooded-complaints-about-care Psychological safety can empower staff to communicate concerns that affect patient safety. This newspaper article reports on Veteran…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863221/psn-pdf
    February 28, 2024 - Using artificial intelligence to improve primary care for patients and clinicians. February 28, 2024 Sarkar U, Bates DW. Using artificial intelligence to improve primary care for patients and clinicians. JAMA Intern Med. 2024;184(4):343-344. doi:10.1001/jamainternmed.2023.7965. https://psnet.ahrq.gov/issue/using-a…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40772/psn-pdf
    November 23, 2011 - Improving perceptions of teamwork climate with the Veterans Health Administration medical team training program. November 23, 2011 Carney BT, West P, Neily J, et al. Improving perceptions of teamwork climate with the Veterans Health Administration medical team training program. Am J Med Qual. 2011;26(6):480-4. do…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46352/psn-pdf
    October 15, 2018 - Optimal Resources for Surgical Quality and Safety. October 15, 2018 Hoyt DB, Ko CY, eds. Chicago, IL: American College of Surgeons; 2017. ISBN: 9780996826242. https://psnet.ahrq.gov/issue/optimal-resources-surgical-quality-and-safety Surgery is complex and involves a wide range of possibilities for error that can r…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46915/psn-pdf
    April 16, 2018 - Postoperative opioid prescribing: Getting it RIGHTT. April 16, 2018 Yorkgitis BK, Brat GA. Postoperative opioid prescribing: Getting it RIGHTT. Am J Surg. 2018;215(4):707- 711. doi:10.1016/j.amjsurg.2018.02.001. https://psnet.ahrq.gov/issue/postoperative-opioid-prescribing-getting-it-rightt Use of mnemonics to rec…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47101/psn-pdf
    December 21, 2018 - Education and reporting of diagnostic errors among physicians in internal medicine training programs. December 21, 2018 Wijesekera TP, Sanders L, Windish DM. Education and Reporting of Diagnostic Errors Among Physicians in Internal Medicine Training Programs. JAMA Intern Med. 2018;178(11):1548-1549. doi:10.1001/ja…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44479/psn-pdf
    September 09, 2015 - Health literacy in primary care practice. September 9, 2015 Hersh L, Salzman B, Snyderman D. Health Literacy in Primary Care Practice. Am Fam Physician. 2015;92(2):118-124. https://psnet.ahrq.gov/issue/health-literacy-primary-care-practice Limited health literacy can lead to patients misunderstanding care instruct…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73429/psn-pdf
    June 23, 2021 - Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. June 23, 2021 Farnborough, UK: Healthcare Safety Investigation Branch; June 2021. https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings Wrong site/wrong patent surgery is a persisten…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45270/psn-pdf
    June 29, 2016 - Using contemporary leadership skills in medication safety programs. June 29, 2016 Hertig JB, Hultgren KE, Weber RJ. Using Contemporary Leadership Skills in Medication Safety Programs. Hosp Pharm. 2016;51(4):338-44. doi:10.1310/hpj5104-338. https://psnet.ahrq.gov/issue/using-contemporary-leadership-skills-medicatio…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44161/psn-pdf
    December 19, 2018 - Among the elderly, many mental illnesses go undiagnosed. December 19, 2018 Bor JS. Among the elderly, many mental illnesses go undiagnosed. Health Aff (Millwood). 2015;34(5):727- 31. doi:10.1377/hlthaff.2015.0314. https://psnet.ahrq.gov/issue/among-elderly-many-mental-illnesses-go-undiagnosed This commentary spot…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42881/psn-pdf
    January 22, 2014 - Speaking up about the dangers of the hidden curriculum. January 22, 2014 Liao JM, Thomas EJ, Bell SK. Speaking up about the dangers of the hidden curriculum. Health Aff (Millwood). 2014;33(1):168-171. doi:10.1377/hlthaff.2013.1073. https://psnet.ahrq.gov/issue/speaking-about-dangers-hidden-curriculum Relating an a…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45015/psn-pdf
    July 18, 2016 - Interhospital transfer handoff practices among US tertiary care centers: a descriptive survey. July 18, 2016 Herrigel DJ, Carroll M, Fanning C, et al. Interhospital transfer handoff practices among US tertiary care centers: A descriptive survey. J Hosp Med. 2016;11(6):413-7. doi:10.1002/jhm.2577. https://psnet.ahr…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42272/psn-pdf
    November 26, 2014 - Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program. November 26, 2014 Graham KL, Marcantonio ER, Huang GC, et al. Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program. J Gen Int…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61097/psn-pdf
    November 04, 2020 - Obstetrician-gynecologist views of pregnancy-related medication safety. November 4, 2020 SteelFisher GK, Hero JO, Caporello HL, et al. Obstetrician-gynecologist views of pregnancy-related medication safety. J Womens Health (Larchmt). 2020;29(8):1113-1121. doi:10.1089/jwh.2019.8007. https://psnet.ahrq.gov/issue/obs…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60819/psn-pdf
    August 19, 2020 - Register-based research of adverse events revealing incomplete records threatening patient safety. August 19, 2020 Kinnunen U-M, Kivekäs E, Palojoki S, et al. Register-based research of adverse events revealing incomplete records threatening patient safety. Stud Health Technol Inform. 2020;270:771-775. doi:10.3233…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42931/psn-pdf
    April 20, 2014 - Assigning a team-based pager for on-call physicians reduces paging errors in a large academic hospital. April 20, 2014 Shieh L, Chi J, Kulik C, et al. Assigning a team-based pager for on-call physicians reduces paging errors in a large academic hospital. Jt Comm J Qual Patient Saf. 2014;40(2):77-82. https://psnet.…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41459/psn-pdf
    August 02, 2012 - The use of simulation in healthcare: from systems issues, to team building, to task training, to education and high stakes examinations. August 2, 2012 Orledge J, Phillips WJ, Murray B, et al. The use of simulation in healthcare: from systems issues, to team building, to task training, to education and high stakes…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39840/psn-pdf
    September 15, 2010 - Wrong-site craniotomy: analysis of 35 cases and systems for prevention. September 15, 2010 Cohen FL, Mendelsohn D, Bernstein M. Wrong-site craniotomy: analysis of 35 cases and systems for prevention. J Neurosurg. 2010;113(3):461-73. doi:10.3171/2009.10.JNS091282. https://psnet.ahrq.gov/issue/wrong-site-craniotomy-…
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