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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50913/psn-pdf
    February 19, 2020 - "Disruptive behavior" in the operating room: A prospective observational study of triggers and effects of tense communication episodes in surgical teams. February 19, 2020 Keller S, Tschan F, Semmer NK, et al. “Disruptive behavior” in the operating room: A prospective observational study of triggers and effects of…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60636/psn-pdf
    July 01, 2020 - Measuring the impact of medication-related interventions on 30-day readmission rates in a skilled nursing facility. July 1, 2020 Amin PB, Bradford CD, Rizos AL, et al. Measuring the Impact of Medication-Related Interventions on 30- Day Readmission Rates in a Skilled Nursing Facility. J Pharm Pract. 2020;33(3):306-3…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74191/psn-pdf
    December 15, 2021 - Race differences in reported "near miss" patient safety events in health care system high reliability organizations. December 15, 2021 Thomas AD, Pandit C, Krevat S. Race differences in reported "near miss" patient safety events in health care system high reliability organizations. J Patient Saf. 2021;17(8):e1605-…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837044/psn-pdf
    May 04, 2022 - How Discrimination in Health Care Affects Older Americans, and What Health Systems and Providers Can Do. May 4, 2022 Doty MM, Horstman C, Shah A et al. Issue Brief. New York, NY: Commonwealth Fund: April 2022. https://psnet.ahrq.gov/issue/how-discrimination-health-care-affects-older-americans-and-what-health- sys…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836760/psn-pdf
    March 16, 2022 - Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020. March 16, 2022 Washington, DC: VA Office of the Inspector General;  February 17, 2022. Report No. 21-01506-76. https://psnet.ahrq.gov/issue/comprehensive-healthcare-i…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845353/psn-pdf
    March 01, 2023 - Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California. March 1, 2023 Washington, DC: VA Office of the Inspector General; February 2, 2023. Report no. 22-01363-52. https://psnet.ahrq.gov/issue/inadequate-outpatient-mental-health-triage-and…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850170/psn-pdf
    June 07, 2023 - A scoping review of distributed cognition in acute care clinical decision-making. June 7, 2023 Wilson E, Daniel M, Rao A, et al. A scoping review of distributed cognition in acute care clinical decision- making. Diagnosis (Berl). 2023;10(2):68-88. doi:10.1515/dx-2022-0095. https://psnet.ahrq.gov/issue/scoping-revi…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74086/psn-pdf
    November 17, 2021 - Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration. November 17, 2021 Soncrant C, Mills PD, Pendley Louis RP, et al. Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration. J Patien…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847054/psn-pdf
    April 05, 2023 - Patient generated research priorities to improve diagnostic safety: a systematic prioritization exercise. April 5, 2023 Zwaan L, Smith KM, Giardina TD, et al. Patient generated research priorities to improve diagnostic safety: a systematic prioritization exercise. Patient Educ Couns. 2023;110:107650. doi:10.1016/j…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50651/psn-pdf
    November 13, 2019 - How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis. November 13, 2019 Schmutz JB, Meier LL, Manser T. How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic rev…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47487/psn-pdf
    November 07, 2018 - Comparative, cross-sectional study of the format, content and timing of medication safety letters issued in Canada, the USA and the UK. November 7, 2018 Bjerre LM, Parlow S, de Launay D, et al. Comparative, cross-sectional study of the format, content and timing of medication safety letters issued in Canada, the U…
  12. psnet.ahrq.gov/issue/communication-and-resolution-programs-emerging-best-practice-addressing-patient-harm
    July 29, 2020 - Upcoming Meeting/Conference Communication and Resolution Programs: An Emerging Best Practice for Addressing Patient Harm. Citation Text: National Association for Healthcare Quality.  August 26, 2021, 1:00–2:00 PM (eastern). Copy Citation Save Print …
  13. psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
    November 08, 2013 - Diffusion of Responsibility Leads to Danger Citation Text: Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47081/psn-pdf
    September 02, 2018 - Beyond Dr. Google: the evidence on consumer-facing digital tools for diagnosis. September 2, 2018 Millenson ML, Baldwin JL, Zipperer L, et al. Beyond Dr. Google: the evidence on consumer-facing digital tools for diagnosis. Diagnosis (Berl). 2018;5(3):95-105. doi:10.1515/dx-2018-0009. https://psnet.ahrq.gov/issue/b…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44174/psn-pdf
    January 06, 2016 - Team training for safer birth. January 6, 2016 Cornthwaite K, Alvarez M, Siassakos D. Team training for safer birth. Best Pract Res Clin Obstet Gynaecol. 2015;29(8):1044-1057. doi:10.1016/j.bpobgyn.2015.03.020. https://psnet.ahrq.gov/issue/team-training-safer-birth Obstetric care is considered a high-risk environm…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42556/psn-pdf
    August 28, 2013 - Findings and Lessons From the Improving Quality Through Clinician Use of Health IT Grant Initiative. August 28, 2013 Rockville, MD: Agency for Healthcare Research and Quality. May 2013. AHRQ Publication No 13-0042-EF. https://psnet.ahrq.gov/issue/findings-and-lessons-improving-quality-through-clinician-use-health-i…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36122/psn-pdf
    January 05, 2017 - Using an MET service to manage hemorrhage post- percutaneous liver biopsy. January 5, 2017 Jones D, Bellomo R, Leong T. Using an MET service to manage hemorrhage post-percutaneous liver biopsy. Jt Comm J Qual Patient Saf. 2006;32(8):459-62, 417. https://psnet.ahrq.gov/issue/using-met-service-manage-hemorrhage-post…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34570/psn-pdf
    March 07, 2005 - Measuring the Success of the Regional Medication Safety Program for Hospitals. March 7, 2005 Pelczarski K, Fricker M, Morris J. Philadelphia, PA: Health Care Improvement Foundation; 2005. https://psnet.ahrq.gov/issue/measuring-success-regional-medication-safety-program-hospitals The Regional Medication Safety Prog…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33882/psn-pdf
    June 01, 2019 - Building a Safety Program Using Principles of Resilience Engineering June 1, 2019 Hegde S, Fairbanks RJ, Bisantz A. Building a Safety Program Using Principles of Resilience Engineering. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering Persp…
  20. psnet.ahrq.gov/primer/pharmacists-role-medication-safety
    March 14, 2018 - Pharmacist's Role in Medication Safety Citation Text: The Pharmacist's Role in Medication Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7…

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