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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854831/psn-pdf
    January 01, 2024 - Medication safety events after acute myocardial infarction among veterans treated at VA versus non-VA hospitals. October 25, 2023 Weeda ER, Ward R, Gebregziabher M, et al. Medication safety events after acute myocardial infarction among veterans treated at VA versus non-VA hospitals. Med Care. 2024;62(2):72-78. do…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73427/psn-pdf
    June 23, 2021 - Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey on United States operating rooms. June 23, 2021 Weprin SA, Meyer D, Li R, et al. Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey on United States operating rooms. Patient Sa…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41404/psn-pdf
    December 31, 2014 - Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial. December 31, 2014 Schnipper JL, Gandhi TK, Wald JS, et al. Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial. J Am Med Inform Assoc. 2012;19(5):728-34. …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37873/psn-pdf
    June 16, 2009 - Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. June 16, 2009 Horwitz LI, Meredith T, Schuur JD, et al. Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. Ann Emerg Med. …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39655/psn-pdf
    July 07, 2010 - Errors of diagnosis in pediatric practice: a multisite survey. July 7, 2010 Singh H, Thomas EJ, Wilson L, et al. Errors of diagnosis in pediatric practice: a multisite survey. Pediatrics. 2010;126(1):70-9. doi:10.1542/peds.2009-3218. https://psnet.ahrq.gov/issue/errors-diagnosis-pediatric-practice-multisite-survey…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44248/psn-pdf
    May 26, 2016 - Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. May 26, 2016 Hempel S, Maggard-Gibbons M, Nguyen DK, et al. Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires : A Systematic Review of Surgical Never Events. JAMA Surg. 2015;150(8):796-805. …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837729/psn-pdf
    July 27, 2022 - Development of a multicomponent intervention to decrease racial bias among healthcare staff. July 27, 2022 Tajeu GS, Juarez L, Williams JH, et al. Development of a multicomponent intervention to decrease racial bias among healthcare staff. J Gen Intern Med. 2022;37(8):1970-1979. doi:10.1007/s11606-022-07464-x. htt…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45754/psn-pdf
    September 01, 2018 - Addressing ambulatory safety and malpractice: the Massachusetts PROMISES project. September 1, 2018 Schiff G, Nieva HR, Griswold P, et al. Addressing Ambulatory Safety and Malpractice: The Massachusetts PROMISES Project. Health Serv Res. 2016;51 Suppl 3:2634-2641. doi:10.1111/1475-6773.12621. https://psnet.ahrq.go…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74139/psn-pdf
    December 01, 2021 - Situation awareness and the mitigation of risk associated with patient deterioration: a meta-narrative review of theories and models and their relevance to nursing practice. December 1, 2021 Walshe N, Ryng S, Drennan J, et al. Situation awareness and the mitigation of risk associated with patient deterioration: a…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74163/psn-pdf
    December 08, 2008 - Follow-up of abnormal screening mammograms among low-income ethnically diverse women: findings from a qualitative study. December 8, 2008 Allen JD, Shelton RC, Harden E, et al. Follow-up of abnormal screening mammograms among low-income ethnically diverse women: findings from a qualitative study. Patient Educ Coun…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866646/psn-pdf
    September 04, 2024 - Adverse events and perceived abandonment: learning from patients' accounts of medical mishaps. September 4, 2024 Schlesinger M, Dhingra I, Fain BA, et al. Adverse events and perceived abandonment: learning from patients’ accounts of medical mishaps. BMJ Open Qual. 2024;13(3):e002848. doi:10.1136/bmjoq-2024- 002848…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850162/psn-pdf
    June 07, 2023 - Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechnical factor study. June 7, 2023 Bourne RS, Jeffries M, Phipps DL, et al. Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechn…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45535/psn-pdf
    January 23, 2017 - Surgical specimen management: a descriptive study of 648 adverse events and near misses. January 23, 2017 Steelman VM, Williams TL, Szekendi MK, et al. Surgical specimen management: a descriptive study of 648 adverse events and near misses. Arch Pathol Lab Med. 2016;140(12):1390-1396. https://psnet.ahrq.gov/issue/…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41898/psn-pdf
    December 05, 2012 - Pharmacy dispensing of electronically discontinued medications. December 5, 2012 Allen AS, Sequist TD. Pharmacy dispensing of electronically discontinued medications. Ann Intern Med. 2012;157(10):700-705. doi:10.7326/0003-4819-157-10-201211200-00006. https://psnet.ahrq.gov/issue/pharmacy-dispensing-electronically-…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851348/psn-pdf
    July 12, 2023 - Widespread misinterpretation of advance directives and Portable Orders for Life-Sustaining Treatments threatens patient safety and causes undertreatment and overtreatment. July 12, 2023 Mirarchi FL, Pope TM. Widespread misinterpretation of advance directives and Portable Orders for Life- Sustaining Treatments thr…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850161/psn-pdf
    June 07, 2023 - Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study. June 7, 2023 Alqenae FA, Steinke DT, Carson-Stevens A, et al. Analysis of the nature and contributory fa…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844043/psn-pdf
    February 08, 2023 - In situ simulation: a strategy to restore patient safety in intensive care units after the COVID-19 pandemic? February 8, 2023 Gómez-Pérez V, Escrivá Peiró D, Sancho-Cantus D, et al. In Situ Simulation: A Strategy to Restore Patient Safety in Intensive Care Units after the COVID-19 Pandemic? Systematic Review. Heal…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41794/psn-pdf
    January 31, 2013 - Safety culture and complications after bariatric surgery. January 31, 2013 Birkmeyer NJO, Finks JF, Greenberg CK, et al. Safety culture and complications after bariatric surgery. Ann Surg. 2013;257(2):260-5. doi:10.1097/SLA.0b013e31826c0085. https://psnet.ahrq.gov/issue/safety-culture-and-complications-after-bariat…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37534/psn-pdf
    February 13, 2008 - Measurable outcomes of quality improvement in the trauma intensive care unit: the impact of a daily quality rounding checklist. February 13, 2008 DuBose JJ, Inaba K, Shiflett A, et al. Measurable outcomes of quality improvement in the trauma intensive care unit: the impact of a daily quality rounding checklist. J …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840153/psn-pdf
    November 16, 2022 - Team debriefing in the COVID-19 pandemic: a qualitative study of a hospital-wide clinical event debriefing program and a novel qualitative model to analyze debriefing content. November 16, 2022 Welch-Horan TB, Mullan PC, Momin Z, et al. Team debriefing in the COVID-19 pandemic: a qualitative study of a hospital-w…
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