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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73595/psn-pdfAugust 11, 2021 - Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs. August 11, 2021 ISMP Medication Safety Alert! Acute care edition. July 29, 2021;26(15);1-5. https://psnet.ahrq.gov/issue/safety-committees-need-proactively-address-risk-accidental-cerebral-injection- … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/838145/psn-pdfSeptember 21, 2022 - Charlie Bourg was on the lookout for veterans harmed by a new VA computer system. He didn’t expect to be one of them. September 21, 2022 Donovan-Smith O. Spokesman-Review. September 11, 2022. https://psnet.ahrq.gov/issue/charlie-bourg-was-lookout-veterans-harmed-new-va-computer-system-he- didnt-expect-be-one… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/50686/psn-pdfJanuary 01, 2020 - 'Whatever you cut, I can fix it': clinical supervisors' interview accounts of allowing trainee failure while guarding patient safety. November 20, 2019 Klasen JM, Driessen E, Teunissen PW, et al. ‘Whatever you cut, I can fix it’: clinical supervisors’ interview accounts of allowing trainee failure while guarding p… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/50820/psn-pdfJanuary 22, 2020 - Associations between a new disruptive behaviors scale and teamwork, patient safety, work-life balance, burnout, and depression. January 22, 2020 Rehder KJ, Adair KC, Hadley A, et al. Associations Between a New Disruptive Behaviors Scale and Teamwork, Patient Safety, Work-Life Balance, Burnout, and Depression. Jt C… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44220/psn-pdfJune 10, 2015 - Building a Culture of Patient Safety Through Simulation: An Interprofessional Learning Model. June 10, 2015 Gallo K, Smith LG, eds. New York, NY: Springer Publishing Company; 2015. ISBN: 9780826169068. https://psnet.ahrq.gov/issue/building-culture-patient-safety-through-simulation-interprofessional-learning- model… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/848086/psn-pdfApril 26, 2023 - Preventable harm in the Canadian organ donation and transplantation system: a descriptive study of missed organ donor identification and referral. April 26, 2023 Zavalkoff S, O’Donnell S, Lalani J, et al. Preventable harm in the Canadian organ donation and transplantation system: a descriptive study of missed orga… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/867015/psn-pdfOctober 23, 2024 - Supporting perioperative safety during a disaster through clinical crisis education. October 23, 2024 Kirkman A, Tripp H, Ward L, et al. Supporting perioperative safety during a disaster through clinical crisis education. AORN J. 2024;120(4):226-237. doi:10.1002/aorn.14217. https://psnet.ahrq.gov/issue/supporting-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41607/psn-pdfJanuary 03, 2017 - Using a risk assessment approach to determine which factors influence whether partially bilingual physicians rely on their non-English language skills or call an interpreter. January 3, 2017 Maul L, Regenstein M, Andres E, et al. Using a risk assessment approach to determine which factors influence whether partia… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/50536/psn-pdfOctober 16, 2019 - The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project October 16, 2019 Jones KJ, Crowe J, Allen JA, et al. The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-expe… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/854988/psn-pdfNovember 01, 2023 - Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit. November 1, 2023 Gifford A, Butcher B, Chima RS, et al. Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit. J Hosp Med. 2023;18(1… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/854835/psn-pdfOctober 25, 2023 - Improving patient safety by shifting power from health professionals to patients. October 25, 2023 BMJ. 2023(383):2219, 2278, 2319, 2331. https://psnet.ahrq.gov/issue/improving-patient-safety-shifting-power-health-professionals-patients This compendium of editorials and opinion pieces discuss “Martha’s Rule,” a ne… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866408/psn-pdfJuly 31, 2024 - Influences of leadership, organizational culture, and hierarchy on raising concerns about patient deterioration: a qualitative study. July 31, 2024 Vehvilainen E, Charles A, Sainsbury J, et al. Influences of leadership, organizational culture, and hierarchy on raising concerns about patient deterioration: a qualit… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/863760/psn-pdfMarch 06, 2024 - Imagining improved interactions: patients' designs to address implicit bias. March 6, 2024 Yang C, Coney L, Mohanraj D, et al. AMIA Annu Symp Proc. 2023;2023:774-783. https://psnet.ahrq.gov/issue/imagining-improved-interactions-patients-designs-address-implicit-bias Implicit biases can compromise decision making a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/836713/psn-pdfMarch 09, 2022 - Benefits of reporting and analyzing nursing students' near-miss medication incidents. March 9, 2022 Dennison S, Freeman M, Giannotti N, et al. Benefits of reporting and analyzing nursing students' near-miss medication incidents. Nurse Educ. 2022;47(4):202-207. doi:10.1097/nne.0000000000001164. https://psnet.ahrq.g… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44430/psn-pdfOctober 28, 2015 - The role of dynamic trade-offs in creating safety—a qualitative study of handover across care boundaries in emergency care. October 28, 2015 Sujan M, Spurgeon P, Cooke M. The role of dynamic trade-offs in creating safety—A qualitative study of handover across care boundaries in emergency care. Reliab Eng Syst Saf.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46844/psn-pdfMarch 07, 2018 - Learning collaboratives: insights and a new taxonomy from AHRQ's two decades of experience. March 7, 2018 Nix M, McNamara P, Genevro J, et al. Learning Collaboratives: Insights And A New Taxonomy From AHRQ's Two Decades Of Experience. Health Aff (Millwood). 2018;37(2):205-212. doi:10.1377/hlthaff.2017.1144. https… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45130/psn-pdfJuly 18, 2018 - Surgical fires: decreasing incidence relies on continued prevention efforts. July 18, 2018 Bruley ME, Arnold TV, Finley E, Deutsch ES, Treadwell JR. PA-PSRS Pa Patient Saf Advis. June 2018;15. https://psnet.ahrq.gov/issue/surgical-fires-decreasing-incidence-relies-continued-prevention-efforts Although surgical fir… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/846448/psn-pdfMarch 22, 2023 - Understanding patient and clinician reported nonroutine events in ambulatory surgery. March 22, 2023 Salwei ME, Anders S, Slagle JM, et al. Understanding patient and clinician reported nonroutine events in ambulatory surgery. J Patient Saf. 2023;19(2):e38-e45. doi:10.1097/pts.0000000000001089. https://psnet.ahrq.g… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46412/psn-pdfOctober 11, 2017 - Team-based care: the changing face of cardiothoracic surgery. October 11, 2017 Crawford TC, Conte J, Sanchez JA. Team-Based Care: The Changing Face of Cardiothoracic Surgery. Surg Clin North Am. 2017;97(4):801-810. doi:10.1016/j.suc.2017.03.003. https://psnet.ahrq.gov/issue/team-based-care-changing-face-cardiothor… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/855091/psn-pdfNovember 08, 2023 - Handoff tool improves transitions from the operating room to the neonatal intensive care unit. November 8, 2023 Gallois JB, Zagory JA, Barkemeyer B, et al. Handoff tool improves transitions from the operating room to the neonatal intensive care unit. Pediatr Qual Saf. 2023;8(5):e695. doi:10.1097/pq9.000000000000069…
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