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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44221/psn-pdf
    September 27, 2016 - Reducing surgical errors: implementing a three-hinge approach to success. September 27, 2016 Landers R. Reducing surgical errors: implementing a three-hinge approach to success. AORN J. 2015;101(6):657-65. doi:10.1016/j.aorn.2015.04.013. https://psnet.ahrq.gov/issue/reducing-surgical-errors-implementing-three-hing…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43220/psn-pdf
    April 03, 2017 - Patient safety teams recognised at BMJ awards. April 3, 2017 Gulland A. Berwick Patient Safety Team: making the NHS a safer place. BMJ. 2014;348(mar28 1). doi:10.1136/bmj.g2404. https://psnet.ahrq.gov/issue/patient-safety-teams-recognised-bmj-awards The Great Ormond Street Hospital Foundation NHS Trust received th…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72761/psn-pdf
    February 17, 2021 - Using ventilator splitters during the COVID-19 pandemic-- letter to health care providers. February 17, 2021 Silver Spring, MD: Division of Industry and Consumer Education, US Food and Drug Administration; February 9. 2021. https://psnet.ahrq.gov/issue/using-ventilator-splitters-during-covid-19-pandemic-letter-hea…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42872/psn-pdf
    December 30, 2014 - Errors in after-hours phone consultations: a simulation study. December 30, 2014 Joffe E, Turley JP, Hwang KO, et al. Errors in after-hours phone consultations: a simulation study. BMJ Qual Saf. 2014;23(5):398-405. doi:10.1136/bmjqs-2013-002243. https://psnet.ahrq.gov/issue/errors-after-hours-phone-consultations-s…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43231/psn-pdf
    July 28, 2014 - Disclosure of adverse events and errors in surgical care: challenges and strategies for improvement. July 28, 2014 Lipira LE, Gallagher TH. Disclosure of adverse events and errors in surgical care: challenges and strategies for improvement. World J Surg. 2014;38(7):1614-21. doi:10.1007/s00268-014-2564-5. https://p…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42105/psn-pdf
    June 28, 2013 - Public perceptions and preferences for patient notification after an unsafe injection. June 28, 2013 Schneider AK, Brinsley-Rainisch KJ, Schaefer MK, et al. Public perceptions and preferences for patient notification after an unsafe injection. J Patient Saf. 2013;9(1):8-12. doi:10.1097/PTS.0b013e318269992d. https:…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44955/psn-pdf
    May 21, 2016 - Accuracy of the Safer Dx Instrument to identify diagnostic errors in primary care. May 21, 2016 Al-Mutairi A, Meyer AND, Thomas EJ, et al. Accuracy of the Safer Dx Instrument to Identify Diagnostic Errors in Primary Care. J Gen Intern Care. 2016;31(6):602-608. doi:10.1007/s11606-016-3601-x. https://psnet.ahrq.gov/…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42277/psn-pdf
    July 02, 2014 - Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study. July 2, 2014 Mitchell EL, Lee DY, Arora S, et al. Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study. Acad Med. 2013;88(6):824-30. doi:10.1097/ACM.0b013…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41188/psn-pdf
    March 07, 2012 - Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients. March 7, 2012 Nakayama DK, Lester SS, Rich DR, et al. Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients. J Pediatr Surg. 2012;47(1):112-8. …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853249/psn-pdf
    September 06, 2023 - How does robotic-assisted surgery change OR safety culture? September 6, 2023 How does robotic-assisted surgery change OR safety culture? AMA J Ethics. 2023;25(8):E615-E623. doi:10.1001/amajethics.2023.615. https://psnet.ahrq.gov/issue/how-does-robotic-assisted-surgery-change-or-safety-culture The safety culture …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43610/psn-pdf
    October 15, 2014 - Preventing medication errors in neonatology: is it a dream? October 15, 2014 Antonucci R, Porcella A. Preventing medication errors in neonatology: Is it a dream? World J Clin Pediatr. 2014;3(3):37-44. doi:10.5409/wjcp.v3.i3.37. https://psnet.ahrq.gov/issue/preventing-medication-errors-neonatology-it-dream Discuss…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46427/psn-pdf
    April 04, 2018 - Improving Diagnosis in Radiology—Progress and Proposals. April 4, 2018 Bruno MA, Johnson K, Argy N, Graber ML, eds. Diagnosis. 2017;4(3):111-191. https://psnet.ahrq.gov/issue/improving-diagnosis-radiology-progress-and-proposals Radiology plays a unique role in the determination of a diagnosis. Cognitive and system…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855105/psn-pdf
    January 01, 2024 - Sentinel Event Alert 68: updated surgical fire prevention for the 21st Century. November 8, 2023 Sentinel Event Alert 68: Updated Surgical Fire Prevention for the 21st Century. Jt Comm J Qual Patient Saf. 2024;50(2):157-160. doi:10.1016/j.jcjq.2023.10.003. https://psnet.ahrq.gov/issue/sentinel-event-alert-68-updat…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47299/psn-pdf
    March 20, 2019 - Unintentionally retained guidewires: a descriptive study of 73 sentinel events. March 20, 2019 Steelman VM, Thenuwara K, Shaw C, et al. Unintentionally Retained Guidewires: A Descriptive Study of 73 Sentinel Events. Jt Comm J Qual Saf. 2019;45(2):81-90. doi:10.1016/j.jcjq.2018.08.003. https://psnet.ahrq.gov/issue/…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36189/psn-pdf
    February 15, 2010 - Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions. February 15, 2010 Pathologists C of A, Valenstein PN, Raab SS, et al. Identification errors involving clinical laboratories: a College of Amer…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43789/psn-pdf
    August 05, 2015 - Do cell phones belong in the operating room? August 5, 2015 Luthra S. Kaiser Health News. July 14, 2015. https://psnet.ahrq.gov/issue/do-cell-phones-belong-operating-room Distractions can lead to care and process omissions. Reporting on the prevalence of mobile technology in the operating room and how it can hinde…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60205/psn-pdf
    April 08, 2020 - How should U.S. hospitals prepare for Coronavirus disease 2019 (COVID-19)? April 8, 2020 Chopra V, Toner E, Waldhorn R, et al. How Should U.S. Hospitals Prepare for Coronavirus Disease 2019 (COVID-19)? Ann Intern Med. 2020;172(9):621-622. doi:10.7326/m20-0907. https://psnet.ahrq.gov/issue/how-should-us-hospitals-p…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39887/psn-pdf
    September 29, 2010 - High-alert medications: shared accountability for risk identification and error prevention. September 29, 2010 Paparella S. High-alert medications: shared accountability for risk identification and error prevention. Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Associat…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43189/psn-pdf
    December 15, 2014 - Twitter as a tool to enhance student engagement during an interprofessional patient safety course. December 15, 2014 Mckay M, Sanko JS, Shekhter I, et al. Twitter as a tool to enhance student engagement during an interprofessional patient safety course. J Interprof Care. 2014;28(6):565-7. doi:10.3109/13561820.2014…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44385/psn-pdf
    October 13, 2015 - Same-hospital readmission rates as a measure of pediatric quality of care. October 13, 2015 Khan A, Nakamura MM, Zaslavsky AM, et al. Same-Hospital Readmission Rates as a Measure of Pediatric Quality of Care. JAMA Pediatr. 2015;169(10):905-12. doi:10.1001/jamapediatrics.2015.1129. https://psnet.ahrq.gov/issue/same…
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