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7701. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36195/psn-pdf
      July 29, 2010 - Keeping our Promises: Research, Practice, and Policy Issues in Health Care Reliability. July 29, 2010 Reinertsen JL, Clancy C, Henriksen K, et al. Health Serv Res. 2006;41(4 Pt 2);1535–1720. https://psnet.ahrq.gov/issue/keeping-our-promises-research-practice-and-policy-issues-health-care- reliability This special…

7702. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73691/psn-pdf
      September 08, 2021 - Pump up the volume: tips for increasing error reporting and decreasing patient harm. September 8, 2021 ISMP Medication Safety Alert! Acute care edition. August 26, 2021;26(17);1-5.  https://psnet.ahrq.gov/issue/pump-volume-tips-increasing-error-reporting-and-decreasing-patient-harm Error reporting is an essen…

7703. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866164/psn-pdf
      June 19, 2024 - What is the effectiveness of reporting systems in promoting learning in healthcare? June 19, 2024 Sehgal A. What is the effectiveness of reporting systems in promoting learning in healthcare? Br J Hosp Med (Lond). 2024;85(4):1-9. doi:10.12968/hmed.2023.0444. https://psnet.ahrq.gov/issue/what-effectiveness-reportin…

7704. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47855/psn-pdf
      June 19, 2019 - Medication Overload: America's Other Drug Problem. June 19, 2019 Brownlee S; Garber J. Brookline, MA: Lown Institute; 2019. https://psnet.ahrq.gov/issue/medication-overload-americas-other-drug-problem Overprescribing is a common problem that contributes to patient harm. This report examines financial, clinical, an…

7705. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848091/psn-pdf
      April 26, 2023 - The high cost of retained surgical items. April 26, 2023 Moorehead LD. Outpatient Surgery. April 5, 2023. https://psnet.ahrq.gov/issue/high-cost-retained-surgical-items Retained surgical items (RSIs) are considered “never events” but continue to be a source of patient harm. This article discusses the various facto…

7706. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43889/psn-pdf
      February 11, 2015 - Data as a catalyst for change: stories from the frontlines. February 11, 2015 Siegal D, Ruoff G. Data as a catalyst for change: stories from the frontlines. J Healthc Risk Manag. 2015;34(3):18-25. doi:10.1002/jhrm.21161. https://psnet.ahrq.gov/issue/data-catalyst-change-stories-frontlines Analysis of malpractice c…

7707. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41502/psn-pdf
      October 03, 2012 - Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. October 3, 2012 Wick EC, Hobson DB, Bennett JL, et al. Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. J Am Coll Surg. 2012;215(2):193-200. doi:10.1016/j…

7708. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47381/psn-pdf
      April 03, 2019 - The role of the patient in patient safety: what can we learn from healthcare's history? April 3, 2019 Leistikow I, Huisman F. The role of the patient in patient safety: What can we learn from healthcare's history? J Patient Saf Risk Manag. 2018;23(4):139-141. doi:10.1177/2516043518791051. https://psnet.ahrq.gov/is…

7709. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39603/psn-pdf
      February 16, 2011 - The Schwartz Center Rounds: evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, and provider support. February 16, 2011 Lown BA, Manning CF. The Schwartz Center Rounds: evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, …

7710. Long-term Care Facilities | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/index.html
      September 01, 2021 - Long-term Care Facilities Resources for long-term care facilities Improving Patient Safety in Long-Term Care Facilities Detecting and promptly reporting changes in a nursing home resident's condition are critical for ensuring the resident's well-being and safety. Such changes may represent a patient s…

7711. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44303/psn-pdf
      January 10, 2018 - Leading Health Care Transformation: A Primer for Clinical Leaders. January 10, 2018 Joshi M, Erb N, Zhang S, Sikka R. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498700184. https://psnet.ahrq.gov/issue/leading-health-care-transformation-primer-clinical-leaders Leadership can enable the change needed to address heal…

7712. Health Information Technology & Patient Safety (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/2006McColm_051111comp.pdf
      June 16, 2021 - Health Information Technology & Patient Safety Health Information Technology & Patient Safety Denni McColm, CIO, Citizens Memorial Healthcare Fast Facts • 74 acute beds • Level III trauma center • 5 LTC facilities • Residential care & independent living • Home care/hospice • 16 physician offices • 1,550 e…

7713. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44784/psn-pdf
      May 03, 2017 - WISH Patient Safety Forum May 3, 2017 World Innovation Summit for Health 2015. Doha, Qatar: Qatar Foundation; February 2015. https://psnet.ahrq.gov/issue/wish-patient-safety-forum The 2015 conference focused on persisting barriers to patient safety worldwide and recommended strategies to achieve lasting improvemen…

7714. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837042/psn-pdf
      April 04, 2022 - Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management. April 4, 2022 Institute for Healthcare Improvement. https://psnet.ahrq.gov/issue/leadership-response-sentinel-event-respectful-effective-crisis-management Crisis management skills are valuable at both the organizational and clinical …

7715. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47597/psn-pdf
      August 07, 2019 - Intentional rounding—an integrative literature review. August 7, 2019 Ryan L, Jackson D, Woods C, et al. Intentional rounding - An integrative literature review. J Adv Nurs. 2019;75(6):1151-1161. doi:10.1111/jan.13897. https://psnet.ahrq.gov/issue/intentional-rounding-integrative-literature-review This review exam…

7716. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41961/psn-pdf
      January 16, 2013 - Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study. January 16, 2013 Williams SD, Phipps D, Ashcroft DM. Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study. Res Social Adm Pharm. 2013;9(1):80-9. doi:10.1…

7717. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74064/psn-pdf
      May 27, 2021 - Achieving zero inequity: lessons learned from patient safety. May 27, 2021 Gandhi TK. NEJM Catalyst. May 27, 2021. https://psnet.ahrq.gov/issue/achieving-zero-inequity-lessons-learned-patient-safety The COVID-19 pandemic has shown a spotlight on bias, disparities, and inequity in the healthcare system. The author…

7718. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50761/psn-pdf
      December 18, 2019 - ‘Largest maternity scandal in NHS history’: Dozens of mothers and babies died on wards of hospital trust, leaked report reveals December 18, 2019 Lintern S. The Independent. November 18, 2019. https://psnet.ahrq.gov/issue/largest-maternity-scandal-nhs-history-dozens-mothers-and-babies-died-wards- hospital-trust …

7719. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850938/psn-pdf
      June 21, 2023 - AI in medicine needs to be carefully deployed to counter bias – and not entrench it. June 21, 2023 Levi R, Gorenstein D. Health Shots. National Public Radio. June 6, 2023. https://psnet.ahrq.gov/issue/ai-medicine-needs-be-carefully-deployed-counter-bias-and-not-entrench-it Systemic biases are present in data …

7720. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37116/psn-pdf
      October 04, 2011 - Adopting National Quality Forum medication safe practices: progress and barriers to hospital implementation. October 4, 2011 Rask KJ, Culler SD, Scott T, et al. Adopting National Quality Forum medication safe practices: Progress and barriers to hospital implementation. J Hosp Med. 2007;2(4). doi:10.1002/jhm.187. …