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4741. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39929/psn-pdf
      July 31, 2012 - The Gift of Failure: New Approaches to Analyzing and Learning from Events and Near-Misses. July 31, 2012 Fahlbruch B, Carroll JS, eds. Safety Sci. 2011;49(1):1-106   https://psnet.ahrq.gov/issue/gift-failure-new-approaches-analyzing-and-learning-events-and-near-misses This special issue discusses how concepts…

4742. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34066/psn-pdf
      January 01, 2013 - Ambulatory patient safety. What we know and need to know. December 22, 2008 Hammons T, Piland NF, Small SD, et al. Ambulatory Patient Safety. What we know and need to know. J Ambul Care Manage. 2013;26(1):63-82. doi:10.1097/00004479-200301000-00007. https://psnet.ahrq.gov/issue/ambulatory-patient-safety-what-we-kn…

4743. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36272/psn-pdf
      June 29, 2011 - Selecting indicators for patient safety at the health system level in OECD countries. June 29, 2011 McLoughlin V, Millar J, Mattke S, et al. Selecting indicators for patient safety at the health system level in OECD countries. Int J Qual Health Care. 2006;18 Suppl 1:14-20. https://psnet.ahrq.gov/issue/selecting-in…

4744. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46644/psn-pdf
      June 20, 2018 - The Science of Teamwork. June 20, 2018 McDaniel SH, Salas E, eds. Am Psychol. 2018;73:305-600. https://psnet.ahrq.gov/issue/science-teamwork Effective teams are core to safe practice in a wide range of work environments. This special issue explores team psychology with an emphasis on high-risk industries such as s…

4745. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39969/psn-pdf
      October 27, 2010 - The Preventable Harm Index: an effective motivator to facilitate the drive to zero. October 27, 2010 Brilli RJ, McClead RE, Davis T, et al. The Preventable Harm Index: an effective motivator to facilitate the drive to zero. J Pediatr. 2010;157(4):681-3. doi:10.1016/j.jpeds.2010.05.046. https://psnet.ahrq.gov/issue…

4746. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39288/psn-pdf
      February 10, 2010 - Patient Safety Act. February 10, 2010 Washington, DC: United States Government Accountability Office; January 28, 2010. Publication GAO-10- 281. https://psnet.ahrq.gov/issue/patient-safety-act This report describes progress in implementing the Patient Safety and Quality Improvement Act. The document details devel…

4747. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42030/psn-pdf
      April 18, 2013 - Reducing hospital errors: interventions that build safety culture. April 18, 2013 Singer SJ, Vogus TJ. Reducing hospital errors: interventions that build safety culture. Annu Rev Public Health. 2013;34:373-96. doi:10.1146/annurev-publhealth-031912-114439. https://psnet.ahrq.gov/issue/reducing-hospital-errors-inter…

4748. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40147/psn-pdf
      January 19, 2011 - Assessing the quality of patient handoffs at care transitions. January 19, 2011 Manser T, Foster S, Gisin S, et al. Assessing the quality of patient handoffs at care transitions. Qual Saf Health Care. 2010;19(6):e44. doi:10.1136/qshc.2009.038430. https://psnet.ahrq.gov/issue/assessing-quality-patient-handoffs-care…

4749. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35951/psn-pdf
      June 14, 2011 - Errors in thyroid gland fine-needle aspiration. June 14, 2011 Raab SS, Vrbin CM, Grzybicki DM, et al. Errors in Thyroid Gland Fine-Needle Aspiration. Am J Clin Pathol. 2007;125(6). doi:10.1309/7rqe37k6439t4pb4. https://psnet.ahrq.gov/issue/errors-thyroid-gland-fine-needle-aspiration This AHRQ–funded study used roo…

4750. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47977/psn-pdf
      August 14, 2019 - Reducing Diagnostic Error: Measurement Considerations. August 14, 2019 National Quality Forum https://psnet.ahrq.gov/issue/reducing-diagnostic-error-measurement-considerations This website tracks the progress of a project focused on the development and review of measures to enhance viability, reporting, accountabi…

4751. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41488/psn-pdf
      May 28, 2014 - Science-based training in patient safety and quality. May 28, 2014 Pronovost P, Weisfeldt ML. Science-based training in patient safety and quality. Ann Intern Med. 2012;157(2):141-3. doi:10.7326/0003-4819-157-2-201207170-00457. https://psnet.ahrq.gov/issue/science-based-training-patient-safety-and-quality This edi…

4752. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42714/psn-pdf
      August 19, 2017 - SWITCH for safety: perioperative hand-off tools. August 19, 2017 Johnson F, Logsdon P, Fournier K, et al. SWITCH for safety: Perioperative hand-off tools. AORN J. 2013;98(5):494-504; quiz 505-7. doi:10.1016/j.aorn.2013.08.016. https://psnet.ahrq.gov/issue/switch-safety-perioperative-hand-tools This commentary desc…

4753. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47053/psn-pdf
      May 23, 2018 - TeamSTEPPS Canada. May 23, 2018 Canadian Patient Safety Institute. https://psnet.ahrq.gov/issue/teamstepps-canada The TeamSTEPPS program was developed to support effective communication and teamwork skills in various health care settings. This site supports the Canadian TeamSTEPPS initiative. The program will pre…

4754. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43534/psn-pdf
      January 22, 2016 - Creating a fellowship curriculum in patient safety and quality. January 22, 2016 Abookire SA, Gandhi TK, Kachalia A, et al. Creating a Fellowship Curriculum in Patient Safety and Quality. Am J Med Qual. 2016;31(1):27-30. doi:10.1177/1062860614549012. https://psnet.ahrq.gov/issue/creating-fellowship-curriculum-pati…

4755. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38939/psn-pdf
      September 09, 2009 - A model framework for patient safety training in chiropractic: a literature synthesis. September 9, 2009 Zaugg B, Wangler M. A model framework for patient safety training in chiropractic: a literature synthesis. J Manipulative Physiol Ther. 2009;32(6):493-499. doi:10.1016/j.jmpt.2009.06.004. https://psnet.ahrq.gov…

4756. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35949/psn-pdf
      May 24, 2006 - Implementation of patient safety initiatives in US hospitals. May 24, 2006 McFadden KL, Stock GN, Gowen CR. Implementation of patient safety initiatives in US hospitals. Int J Oper Prod Manag. 2006;26(3):326-347. doi:10.1108/01443570610651052. https://psnet.ahrq.gov/issue/implementation-patient-safety-initiatives-…

4757. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36950/psn-pdf
      September 09, 2011 - Integrating quality and safety content into clinical teaching in the acute care setting. September 9, 2011 Day L, Smith EL. Integrating quality and safety content into clinical teaching in the acute care setting. Nurs Outlook. 2007;55(3). doi:10.1016/j.outlook.2007.03.002. https://psnet.ahrq.gov/issue/integrating-…

4758. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42332/psn-pdf
      June 12, 2013 - Quality improvement through implementation of discharge order reconciliation. June 12, 2013 Lu Y, Clifford P, Bjorneby A, et al. Quality improvement through implementation of discharge order reconciliation. Am J Health Syst Pharm. 2013;70(9):815-20. doi:10.2146/ajhp120050. https://psnet.ahrq.gov/issue/quality-impr…

4759. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45583/psn-pdf
      January 18, 2017 - ASHP IV Adult Continuous Infusions. January 18, 2017 Bethesda, MD: American Society of Health-System Pharmacists; 2016. https://psnet.ahrq.gov/issue/ashp-iv-adult-continuous-infusions Miscalculations of intravenous infusion concentrations can result in patient harm. Representing the first phase of a standards deve…

4760. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37704/psn-pdf
      April 23, 2008 - Decreasing paediatric prescribing errors in a district general hospital. April 23, 2008 Davey AL, Britland A, Naylor RJ. Decreasing paediatric prescribing errors in a district general hospital. Qual Saf Health Care. 2008;17(2):146-9. doi:10.1136/qshc.2006.021212. https://psnet.ahrq.gov/issue/decreasing-paediatric-…