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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866562/psn-pdf
    January 01, 2025 - Understanding the challenges and successes of implementing 'hybrid' interventions in healthcare settings: findings from a process evaluation of a patient involvement trial. August 21, 2024 Hampton S, Murray J, Lawton R, et al. Understanding the challenges and successes of implementing ‘hybrid’ interventions in he…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866113/psn-pdf
    June 12, 2024 - Reducing the risk of delayed colorectal cancer diagnoses through an ambulatory safety net collaborative. June 12, 2024 Moyal-Smith R, Elam M, Boulanger J, et al. Reducing the risk of delayed colorectal cancer diagnoses through an ambulatory safety net collaborative. Jt Comm J Qual Patient Saf. 2024;50(10):690-699. …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865806/psn-pdf
    May 08, 2024 - Entangled in complexity: an ethnographic study of organizational adaptability and safe care transitions for patients with complex care needs. May 8, 2024 Hedqvist A?T, Praetorius G, Ekstedt M, et al. Entangled in complexity: an ethnographic study of organizational adaptability and safe care transitions for patient…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60858/psn-pdf
    August 26, 2020 - When the Meds Don’t Reach the Bed August 26, 2020 Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed The Case A 69-year-old man with cognitive impairment and marginal housing was admitted for acute exacerbation of chronic obs…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72650/psn-pdf
    January 20, 2021 - A roadmap to advance patient safety in ambulatory care. January 20, 2021 Singh H, Carayon P. A roadmap to advance patient safety in ambulatory care. JAMA. 2020;324(24):2481- 2482. doi:10.1001/jama.2020.18551. https://psnet.ahrq.gov/issue/roadmap-advance-patient-safety-ambulatory-care Preventable harm, such as diag…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840475/psn-pdf
    November 30, 2022 - Complexity and challenges of the clinical diagnosis and management of Long COVID. November 30, 2022 O’Hare AM, Vig EK, Iwashyna TJ, et al. Complexity and challenges of the clinical diagnosis and management of Long COVID. JAMA Netw Open. 2022;5(11):e2240332. doi:10.1001/jamanetworkopen.2022.40332. https://psnet.ah…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73714/psn-pdf
    September 15, 2021 - Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020. September 15, 2021 Washington, DC: Veterans Affairs Office of Inspector General; August 26, 2021. Report No. 21-01502-240. https://psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-f…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836836/psn-pdf
    March 30, 2022 - Deficiencies after the New Electronic Health Record Go- Live at the Mann-Grandstaff VA Medical Center in Spokane, WA. March 30, 2022 Washington, DC: VA Office of Inspector General; March 17, 2022. https://psnet.ahrq.gov/issue/deficiencies-after-new-electronic-health-record-go-live-mann-grandstaff-va- medical-cent…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840487/psn-pdf
    November 30, 2022 - Interprofessional team collaboration and work environment health in 68 US intensive care units. November 30, 2022 Pun BT, Jun J, Tan A, et al. Interprofessional team collaboration and work environment health in 68 US intensive care units. Am J Crit Care. 2022;31(6):443-451. doi:10.4037/ajcc2022546. https://psnet.a…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845347/psn-pdf
    March 01, 2023 - Race differences in a malpractice event database in a large healthcare system. March 1, 2023 Thomas AD, Pandit C, Krevat S. Race differences in a malpractice event database in a large healthcare system. J Patient Saf. 2023;19(2):67-70. doi:10.1097/pts.0000000000001090. https://psnet.ahrq.gov/issue/race-differences…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72643/psn-pdf
    January 13, 2021 - Ockenden Report. Emerging Fndings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust. January 13, 2021 London UK: Crown Copyright; December 10, 2020. ISBN: 9781528623049.   https://psnet.ahrq.gov/issue/ockenden-report-emerging-fndings-a…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72654/psn-pdf
    January 20, 2020 - What is an ethically informed approach to managing patient safety risk during discharge planning? January 20, 2020 West JC. What Is an Ethically Informed Approach to Managing Patient Safety Risk During Discharge Planning? AMA J Ethics. 2020;22(!1):e919-e923. doi:10.1001/amajethics.2020.919. https://psnet.ahrq.gov/…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73857/psn-pdf
    September 22, 2021 - A theoretical model of flow disruptions for the anesthesia team during cardiovascular surgery. September 22, 2021 Boquet A, Cohen T, Diljohn F, et al. A theoretical model of flow disruptions for the anesthesia team during cardiovascular surgery. J Patient Saf. 2021;17(6):e534-e539. doi:10.1097/pts.0000000000000406.…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36226/psn-pdf
    August 30, 2006 - Framework for a High Performance Health System for the United States. August 30, 2006 Mongan JJ. New York, NY; The Commonwealth Fund: 2006. https://psnet.ahrq.gov/issue/framework-high-performance-health-system-united-states This report calls for providing "safe, well-coordinated, accessible, and efficient" care th…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45466/psn-pdf
    September 07, 2016 - Building a highway to quality health care. September 7, 2016 Watson S, Pronovost P. Building a Highway to Quality Health Care. J Patient Saf. 2016;12(3):165-6. doi:10.1097/PTS.0000000000000074. https://psnet.ahrq.gov/issue/building-highway-quality-health-care Substantial progress has been made in improving health …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47132/psn-pdf
    June 28, 2018 - National Steering Committee for Patient Safety. June 28, 2018 Agency for Healthcare Research and Quality and the Institute for Healthcare Improvement. https://psnet.ahrq.gov/issue/national-steering-committee-patient-safety Preventable patient harm is a global public health concern. This announcement highlights a ne…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38125/psn-pdf
    January 11, 2017 - 2008 John M. Eisenberg Patient Safety and Quality Awards. January 11, 2017 Jt Comm J Qual Patient Saf. 2008;34(12):691-712. https://psnet.ahrq.gov/issue/2008-john-m-eisenberg-patient-safety-and-quality-awards The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853969/psn-pdf
    September 27, 2023 - Perceptions of chief clinical information officers on the state of electronic health records systems interoperability in NHS England: a qualitative interview study. September 27, 2023 Li E, Lounsbury O, Clarke J, et al. Perceptions of chief clinical information officers on the state of electronic health records sy…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852750/psn-pdf
    August 23, 2023 - Cognitive biases and moral characteristics of healthcare workers and their treatment approach for persons with advanced dementia in acute care settings. August 23, 2023 Erel M, Marcus E-L, DeKeyser Ganz F. Cognitive biases and moral characteristics of healthcare workers and their treatment approach for persons wit…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49415/psn-pdf
    September 01, 2003 - Intubation Mishap September 1, 2003 Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/intubation-mishap Case Objectives To understand and apply a structured method of human factors case analysis To describe the key components of effective teamwork To understand the imp…

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