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9141. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867683/psn-pdf
      March 05, 2025 - Ambulatory medication errors and adverse events involved in medicine-related malpractice cases from 2011 to 2021. March 5, 2025 Boisvert S, Nelson M, Ross J. Ambulatory medication errors and adverse events involved in medicine- related malpractice cases from 2011 to 2021. J Patient Saf. 2025;21(2):111-117. doi:10…

9142. Learn From Defects - Implementation Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/learn.html
      April 01, 2017 - Learn From Defects - Implementation Guide AHRQ Safety Program for Ambulatory Surgery Purpose: To identify the types of systems that contributed to the defect (an event or situation that you do not want to happen again) and to plan the followup steps needed to improve safety. Who should use this tool? Seni…

9143. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47116/psn-pdf
      August 15, 2018 - Thematic analysis of women's perspectives on the meaning of safety during hospital-based birth. August 15, 2018 Lyndon A, Malana J, Hedli LC, et al. Thematic Analysis of Women's Perspectives on the Meaning of Safety During Hospital-Based Birth. J Obstet Gynecol Neonatal Nurs. 2018;47(3):324-332. doi:10.1016/j.jogn…

9144. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836752/psn-pdf
      March 16, 2022 - The necessary leadership skillsets for the high-reliability organization framework adoption within acute healthcare organizations. March 16, 2022 Logan?Athmer AL. The necessary leadership skillsets for the high?reliability organization framework adoption within acute healthcare organizations. J Healthc Risk Manag.…

9145. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73416/psn-pdf
      June 23, 2021 - An observational study of postoperative handoff standardization failures. June 23, 2021 Abraham J, Meng A, Sona C, et al. An observational study of postoperative handoff standardization failures. Int J Med Inform. 2021;151:104458. doi:10.1016/j.ijmedinf.2021.104458. https://psnet.ahrq.gov/issue/observational-study…

9146. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/863225/psn-pdf
      February 28, 2024 - Revealing Disparities: Health Care Workers’ Observations of Discrimination Against Patients. February 28, 2024 Fernandez H, Ayo-Vaughan M, Zephyrin LC, et al. New York, NY: The Commonwealth Fund; February 15, 2024. https://psnet.ahrq.gov/issue/revealing-disparities-health-care-workers-observations-discrimination-a…

9147. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838082/psn-pdf
      September 14, 2022 - Organizational factors that promote error reporting in healthcare: a scoping review. September 14, 2022 Wawersik D, Palaganas J. Organizational factors that promote error reporting in healthcare: a scoping review. J Healthc Manag. 2022;67(4):283-301. doi:10.1097/jhm-d-21-00166. https://psnet.ahrq.gov/issue/organiz…

9148. Checklist | Digital Healthcare Research
      digital.ahrq.gov/document-type/checklist
      January 01, 2023 - Checklist GI Clinic Registry: Scripts, Protocols, Processes for Panel Managers Description This document is a comprehensive protocol for colorectal cancer screening followup using a population health management tool. Document Source Measuring and Improving Ambulatory…

9149. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866166/psn-pdf
      June 19, 2024 - Understanding risk factors for complaints against pharmacists: a content analysis. June 19, 2024 Wang Y, Ram S (S), Scahill S. Understanding risk factors for complaints against pharmacists: a content analysis. J Patient Saf. 2024;20(4):e18-e28. doi:10.1097/pts.0000000000001217. https://psnet.ahrq.gov/issue/underst…

9150. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35207/psn-pdf
      December 19, 2009 - Patient safety concerns arising from test results that return after hospital discharge. December 19, 2009 Roy CL, Poon EG, Karson A, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143(2):121-128. https://psnet.ahrq.gov/issue/patient-safety-concer…

9151. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45579/psn-pdf
      November 01, 2017 - Factors influencing patient safety during postoperative handover. November 1, 2017 Rose M, Newman SD. AANA J. 2016;84:329-338. https://psnet.ahrq.gov/issue/factors-influencing-patient-safety-during-postoperative-handover Patient handoffs between care teams are vulnerable to error. This scoping review explored the …

9152. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36088/psn-pdf
      September 28, 2010 - Impact and implications of disruptive behavior in the perioperative arena. September 28, 2010 Rosenstein AH, O'Daniel M. Impact and implications of disruptive behavior in the perioperative arena. J Am Coll Surg. 2006;203(1):96-105. https://psnet.ahrq.gov/issue/impact-and-implications-disruptive-behavior-perioperat…

9153. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35977/psn-pdf
      February 17, 2011 - Making patient safety the centerpiece of medical liability reform. February 17, 2011 Clinton HR, Obama B. Making Patient Safety the Centerpiece of Medical Liability Reform. New England Journal of Medicine. 2006;354(21). doi:10.1056/nejmp068100. https://psnet.ahrq.gov/issue/making-patient-safety-centerpiece-medical…

9154. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73968/psn-pdf
      October 13, 2021 - Institution of just culture physician peer review in an academic medical center. October 13, 2021 Volkar JK, Phrampus P, English D, et al. Institution of just culture physician peer review in an academic medical center. J Patient Saf. 2021;17(7):e689-e693. doi:10.1097/pts.0000000000000449. https://psnet.ahrq.gov/i…

9155. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47538/psn-pdf
      January 23, 2019 - What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff. January 23, 2019 Keers RN, Plácido M, Bennett K, et al. What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff. PLoS One. 2018;13(10):e0206233. …

9156. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47802/psn-pdf
      March 04, 2019 - The path to diagnostic excellence includes feedback to calibrate how clinicians think. March 4, 2019 Meyer AND, Singh H. The Path to Diagnostic Excellence Includes Feedback to Calibrate How Clinicians Think. JAMA. 2019;321(8):737-738. doi:10.1001/jama.2019.0113. https://psnet.ahrq.gov/issue/path-diagnostic-excelle…

9157. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44621/psn-pdf
      February 10, 2016 - Young surgeons on speaking up: when and how surgical trainees voice concerns about supervisors' clinical decisions. February 10, 2016 Sur MD, Schindler N, Singh P, et al. Young surgeons on speaking up: when and how surgical trainees voice concerns about supervisors' clinical decisions. Am J Surg. 2016;211(2):437-4…

9158. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36559/psn-pdf
      July 14, 2010 - Description and evaluation of an interprofessional patient safety course for health professions and related sciences students. July 14, 2010 Galt KA, Paschal KA, O'Brien RL, et al. Description and Evaluation of an Interprofessional Patient Safety Course for Health Professions and Related Sciences Students. J Patie…

9159. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47520/psn-pdf
      February 06, 2019 - Improving patient safety in developing countries—moving towards an integrated approach. February 6, 2019 Elmontsri M, Banarsee R, Majeed A. Improving patient safety in developing countries - moving towards an integrated approach. JRSM Open. 2018;9(11):2054270418786112. doi:10.1177/2054270418786112. https://psnet.a…

9160. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848810/psn-pdf
      May 10, 2023 - Factors contributing to preventing operating room "never events": a machine learning analysis. May 10, 2023 Arad D, Rosenfeld A, Magnezi R. Factors contributing to preventing operating room “never events”: a machine learning analysis. Patient Saf Surg. 2023;17(1):6. doi:10.1186/s13037-023-00356-x. https://psnet.ah…