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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46336/psn-pdf
    August 23, 2017 - Improving the Working Environment for Safe Surgical Care. August 23, 2017 Short-Life Working Group on Hospital Reports. Edinburgh, Scotland: Royal College of Surgeons of Edinburgh; July 31, 2017. https://psnet.ahrq.gov/issue/improving-working-environment-safe-surgical-care Surgical training is demanding and can r…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44221/psn-pdf
    September 27, 2016 - Reducing surgical errors: implementing a three-hinge approach to success. September 27, 2016 Landers R. Reducing surgical errors: implementing a three-hinge approach to success. AORN J. 2015;101(6):657-65. doi:10.1016/j.aorn.2015.04.013. https://psnet.ahrq.gov/issue/reducing-surgical-errors-implementing-three-hing…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47067/psn-pdf
    May 16, 2018 - Senior staff safety rounds: a commitment to ensure safety is the top priority. May 16, 2018 O'Connell RT, Ivy ME. NEJM Catalyst. May 1, 2018. https://psnet.ahrq.gov/issue/senior-staff-safety-rounds-commitment-ensure-safety-top-priority Leadership participation at the front lines can drive safety improvement work. …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40105/psn-pdf
    December 22, 2010 - Enhancing patient safety in the pediatric emergency department: teams, communication, and lessons from crew resource management. December 22, 2010 Pruitt CM, Liebelt EL. Enhancing patient safety in the pediatric emergency department: teams, communication, and lessons from crew resource management. Pediatr Emerg Ca…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38108/psn-pdf
    September 30, 2014 - No more blame & shame: developing event-reporting systems may go a long way to reducing patient care errors in EMS. September 30, 2014 Rajasekaran K, Fairbanks RJ, Shah M. No more blame & shame. Developing event-reporting systems may go a long way to reducing patient care errors in EMS. EMS magazine. 2008;37(9):61…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38945/psn-pdf
    November 25, 2009 - The negative impact of nurse-physician disruptive behavior on patient safety: a review of the literature. November 25, 2009 Saxton R, Hines T, Enriquez M. The negative impact of nurse-physician disruptive behavior on patient safety: a review of the literature. J Patient Saf. 2009;5(3):180-183. doi:10.1097/pts.0b013…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45567/psn-pdf
    October 12, 2016 - Insulin Pens Devices. October 12, 2016 Am J Health Syst Pharm. 2016;73(19 suppl 5);s1-s47. https://psnet.ahrq.gov/issue/insulin-pens-devices As a high-alert medication, insulin has the potential to result in serious patient harm if administered incorrectly. Articles in this special issue discuss recommendations de…

  8. Improving Care Delivery Through Lean: Implementation Case Studies | Agency for Healthcare Research and Quality

    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Improving Care Delivery Through Lean: Implementation Case Studies Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Health…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849606/psn-pdf
    May 31, 2023 - The Patient Safety Adoption Framework: a practical framework to bridge the know-do gap. May 31, 2023 Moyal-Smith R, Margo J, Maloney FL, et al. J Patient Saf. 2023;19(4):243-248. https://psnet.ahrq.gov/issue/patient-safety-adoption-framework-practical-framework-bridge-know-do-gap Individual, team, and organization…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48169/psn-pdf
    July 24, 2019 - 50 Years of Inquiries in the National Health Service. July 24, 2019 Polit Q. 2019;90:177-342. https://psnet.ahrq.gov/issue/50-years-inquiries-national-health-service The National Health Service strategy of publishing their inquiries into systematic poor care in the health service is a model of transparency. Articl…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45257/psn-pdf
    July 27, 2016 - Exploring approaches to patient safety: the case of spinal manipulation therapy. July 27, 2016 Rozmovits L, Mior S, Boon H. Exploring approaches to patient safety: the case of spinal manipulation therapy. BMC Complement Altern Med. 2016;16:164. doi:10.1186/s12906-016-1149-2. https://psnet.ahrq.gov/issue/exploring-…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39789/psn-pdf
    August 25, 2010 - Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections. August 25, 2010 Sawyer M, Weeks K, Goeschel CA, et al. Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections. Crit Care Med. 201…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47645/psn-pdf
    April 17, 2019 - When a nurse is prosecuted for a fatal medical mistake, does it make medicine safer? April 17, 2019 Gordon M. Health Shots. National Public Radio. April 10, 2019. https://psnet.ahrq.gov/issue/when-nurse-prosecuted-fatal-medical-mistake-does-it-make-medicine-safer Punitive responses to medical errors persist despit…

  14. Training Module 2 — Core Team Discussion Guide | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/infection-prevention/environment-and-equipment/core-discussion.html
    March 01, 2017 - Training Module 2 — Core Team Discussion Guide AHRQ Safety Program for Long-Term Care: HAIs/CAUTI Clean Equipment and Environment: Knowledge and Practice Directions Answer the following questions to help reflect on how you can prepare to discuss cleaning and disinfection practices at your faci…

  15. Action Planning for the SOPS™ Surveys Infographic (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/action-planning-webcast-graphic.pdf
    February 01, 2019 - Action Planning for the SOPS™ Surveys Infographic Action Planning for the SOPSTM  Surveys January 2019 Webcast Highlights AHRQ's Surveys on Patient Safety CultureTM(SOPS TM) Action Planning Tool guides survey users seeking to improve patient safety culture through the action planning process. The Action Plann…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47182/psn-pdf
    January 01, 2021 - Sustained impact of a pediatric resident-led patient safety council. August 1, 2018 Parente V, Feeney C, Page L, et al. Sustained Impact of a Pediatric Resident-Led Patient Safety Council. J Patient Saf. 2021;17(8):e1346-e1357. doi:10.1097/PTS.0000000000000495. https://psnet.ahrq.gov/issue/sustained-impact-pediatr…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837667/psn-pdf
    July 13, 2022 - Challenges and opportunities of patient safety event reporting. July 13, 2022 Gong Y. Challenges and opportunities of patient safety event reporting. Stud Health Technol Inform. 2022;291:133-150. doi:10.3233/shti220014. https://psnet.ahrq.gov/issue/challenges-and-opportunities-patient-safety-event-reporting Repor…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865347/psn-pdf
    March 27, 2024 - Safety and Human Performance in the Operating Room and Other Extreme Environments. March 27, 2024 Ruskin KJ, ed. Int Anesthesiol Clin. 2024;62(2):1-65. https://psnet.ahrq.gov/issue/safety-and-human-performance-operating-room-and-other-extreme- environments Anesthesia is a vital component of surgical care that can…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47997/psn-pdf
    May 08, 2019 - Blind spots in the science of safety. May 8, 2019 Bosk CL, Pedersen KZ. Blind spots in the science of safety. Lancet. 2019;393(10175):978-979. doi:10.1016/S0140-6736(19)30441-6. https://psnet.ahrq.gov/issue/blind-spots-science-safety Safety sciences offer methods to enhance processes and develop organizational cul…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39832/psn-pdf
    September 08, 2010 - Unintended transplantation of three organs from an HIV- positive donor: report of the analysis of an adverse event in a regional health care service in Italy. September 8, 2010 Bellandi T, Albolino S, Tartaglia R, et al. Unintended transplantation of three organs from an HIV-positive donor: report of the analysis …
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