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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45015/psn-pdf
    July 18, 2016 - Interhospital transfer handoff practices among US tertiary care centers: a descriptive survey. July 18, 2016 Herrigel DJ, Carroll M, Fanning C, et al. Interhospital transfer handoff practices among US tertiary care centers: A descriptive survey. J Hosp Med. 2016;11(6):413-7. doi:10.1002/jhm.2577. https://psnet.ahr…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44638/psn-pdf
    May 18, 2016 - Developing an appreciation of patient safety: analysis of interprofessional student experiences with health mentors. May 18, 2016 Langlois S. Developing an appreciation of patient safety: analysis of interprofessional student experiences with health mentors. Perspect Med Educ. 2016;5(2):88-94. doi:10.1007/s40037-0…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35048/psn-pdf
    June 22, 2009 - Reduction in warfarin adverse events requiring patient hospitalization after implementation of a pharmacist- managed anticoagulation service. June 22, 2009 Locke C, Ravnan SL, Patel R, et al. Reduction in warfarin adverse events requiring patient hospitalization after implementation of a pharmacist-managed anticoa…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43184/psn-pdf
    May 14, 2014 - Often overlooked problems with handoffs: from the intensive care unit to the operating room. May 14, 2014 Evans AS, Yee M-S, Hogue CW. Often overlooked problems with handoffs: from the intensive care unit to the operating room. Anesth Analg. 2014;118(3):687-9. doi:10.1213/ANE.0000000000000075. https://psnet.ahrq.g…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47055/psn-pdf
    May 23, 2018 - Surgical checklists save lives—but once in a while, they don't. Why? May 23, 2018 Mukherjee S. New York Times Magazine. May 9, 2018. https://psnet.ahrq.gov/issue/surgical-checklists-save-lives-once-while-they-dont-why Checklists can coordinate action and communication to augment safety, but human and system factor…
  6. psnet.ahrq.gov/web-mm/intubation-mishap
    April 26, 2023 - SPOTLIGHT CASE Intubation Mishap Citation Text: Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …
  7. psnet.ahrq.gov/web-mm/preventable-transfer-hospital
    March 31, 2022 - Preventable Transfer to the Hospital Citation Text: Agrawal G, Kashkouli P, Bakerjian D. Preventable Transfer to the Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar Bi…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33935/psn-pdf
    February 05, 2018 - The incidence and severity of adverse events affecting patients after discharge from the hospital. February 5, 2018 Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-7. https://psnet.ahrq.gov/…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46217/psn-pdf
    January 30, 2018 - Safer and more appropriate opioid prescribing: a large healthcare system's comprehensive approach. January 30, 2018 Losby JL, Hyatt JD, Kanter MH, et al. Safer and more appropriate opioid prescribing: a large healthcare system's comprehensive approach. J Eval Clin Pract. 2017;23(6):1173-1179. doi:10.1111/jep.12756.…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47205/psn-pdf
    July 25, 2018 - Teamwork and Teamwork Training in Healthcare. July 25, 2018 Teamwork and Teamwork Training in Health care: An Integration and a Path Forward. Buljac-Samardzic M, Dekker-van Doorn C, Maynard MT, eds. Group Org Manag. 2018;43(3):351-527. doi:10.1177/1059601118774669. https://psnet.ahrq.gov/issue/teamwork-and-teamwor…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37342/psn-pdf
    December 23, 2012 - Toward higher-performance health systems: adults' health care experiences in seven countries, 2007. December 23, 2012 Schoen C, Osborn R, Doty M, et al. Toward higher-performance health systems: adults' health care experiences in seven countries, 2007. Health Aff (Millwood). 2007;26(6):w717-734. https://psnet.ahrq…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47065/psn-pdf
    June 20, 2018 - The complexity, diversity, and science of primary care teams. June 20, 2018 Fiscella K, McDaniel SH. The complexity, diversity, and science of primary care teams. Amer Psychol. 2018;73(4):451-467. doi:10.1037/amp0000244. https://psnet.ahrq.gov/issue/complexity-diversity-and-science-primary-care-teams Teamwork is …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36529/psn-pdf
    August 09, 2011 - 5 Million Lives Campaign. August 9, 2011 Institute for Healthcare Improvement; IHI https://psnet.ahrq.gov/issue/5-million-lives-campaign The Institute for Healthcare Improvement's 100,000 Lives Campaign successfully engaged more than 3,000 US hospitals in a coordinated effort to reduce preventable inpatient deaths…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46912/psn-pdf
    March 28, 2018 - Ignoring the Alarms: How NHS Eating Disorder Services Are Failing Patients. March 28, 2018 London, UK: Parliamentary and Health Service Ombudsman; 2017. ISBN: 9781528601344. https://psnet.ahrq.gov/issue/ignoring-alarms-how-nhs-eating-disorder-services-are-failing-patients Patients with mental health conditions fac…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46409/psn-pdf
    November 08, 2017 - 'No one is coming': hospice patients abandoned at death's door. November 8, 2017 Aleccia J; Bailey M. https://psnet.ahrq.gov/issue/no-one-coming-hospice-patients-abandoned-deaths-door Patient safety in ambulatory hospice care is ill defined. Reporting on safety concerns associated with hospice care, including poo…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35112/psn-pdf
    June 22, 2009 - Medication safety in older adults: home-based practice patterns. June 22, 2009 Metlay JP, Cohen A, Polsky D, et al. Medication safety in older adults: home-based practice patterns. J Am Geriatr Soc. 2005;53(6):976-982. https://psnet.ahrq.gov/issue/medication-safety-older-adults-home-based-practice-patterns This s…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44868/psn-pdf
    June 17, 2016 - Patient safety and the problem of many hands. June 17, 2016 Dixon-Woods M, Pronovost P. Patient safety and the problem of many hands. BMJ Qual Saf. 2016;25(7):485-488. doi:10.1136/bmjqs-2016-005232. https://psnet.ahrq.gov/issue/patient-safety-and-problem-many-hands Although individual and organizational accountabi…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33925/psn-pdf
    December 18, 2008 - Drug-related morbidity and mortality and the economic impact of pharmaceutical care. December 18, 2008 Johnson JA, Bootman JL. Drug-related morbidity and mortality and the economic impact of pharmaceutical care. Am J Health Syst Pharm. 1997;54(5):554-8. https://psnet.ahrq.gov/issue/drug-related-morbidity-and-morta…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44901/psn-pdf
    March 30, 2016 - Medication safety pharmacy technician in a large, tertiary care, community hospital. March 30, 2016 Brown KN, Bergsbaken J, Reichard JS. Medication safety pharmacy technician in a large, tertiary care, community hospital. Am J Health Syst Pharm. 2016;73(4):188-191. doi:10.2146/ajhp150098. https://psnet.ahrq.gov/is…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72566/psn-pdf
    January 01, 2021 - Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review. December 16, 2020 Avery AJ, Sheehan C, Bell BG, et al. Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review. BMJ Qual Saf. 2021;30(…

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