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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38621/psn-pdf
    February 18, 2011 - Process of care failures in breast cancer diagnosis. February 18, 2011 Weingart SN, Saadeh MG, Simchowitz B, et al. Process of care failures in breast cancer diagnosis. J Gen Intern Med. 2009;24(6):702-709. doi:10.1007/s11606-009-0982-0. https://psnet.ahrq.gov/issue/process-care-failures-breast-cancer-diagnosis Di…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43401/psn-pdf
    August 02, 2015 - Morning handover of on-call issues: opportunities for improvement. August 2, 2015 Devlin MK, Kozij NK, Kiss A, et al. Morning handover of on-call issues: opportunities for improvement. JAMA Intern Med. 2014;174(9):1479-85. doi:10.1001/jamainternmed.2014.3033. https://psnet.ahrq.gov/issue/morning-handover-call-issu…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39063/psn-pdf
    December 17, 2009 - Safety and risk management interventions in hospitals: a systematic review of the literature. December 17, 2009 Dückers M, Faber M, Cruijsberg J, et al. Safety and risk management interventions in hospitals: a systematic review of the literature. Med Care Res Rev. 2009;66(6 Suppl):90S-119S. doi:10.1177/10775587093…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44683/psn-pdf
    June 21, 2016 - Physician spending and subsequent risk of malpractice claims: observational study. June 21, 2016 Jena AB, Schoemaker L, Bhattacharya J, et al. Physician spending and subsequent risk of malpractice claims: observational study. BMJ. 2015;351:h5516. doi:10.1136/bmj.h5516. https://psnet.ahrq.gov/issue/physician-spendi…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43176/psn-pdf
    July 03, 2014 - Patient safety in the era of the 80-hour workweek. July 3, 2014 Shelton J, Kummerow K, Phillips S, et al. Patient safety in the era of the 80-hour workweek. J Surg Educ. 2014;71(4):551-9. doi:10.1016/j.jsurg.2013.12.011. https://psnet.ahrq.gov/issue/patient-safety-era-80-hour-workweek Regulations intended to reduc…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45375/psn-pdf
    September 27, 2016 - Association of a web-based handoff tool with rates of medical errors. September 27, 2016 Mueller SK, Yoon CS, Schnipper JL. Association of a Web-Based Handoff Tool With Rates of Medical Errors. JAMA Intern Med. 2016;176(9):1400-2. doi:10.1001/jamainternmed.2016.4258. https://psnet.ahrq.gov/issue/association-web-ba…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45509/psn-pdf
    September 28, 2016 - Computerized triggers of big data to detect delays in follow-up of chest imaging results. September 28, 2016 Murphy DR, Meyer AND, Bhise V, et al. Computerized Triggers of Big Data to Detect Delays in Follow-up of Chest Imaging Results. Chest. 2016;150(3):613-20. doi:10.1016/j.chest.2016.05.001. https://psnet.ahrq…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48150/psn-pdf
    August 21, 2019 - Communication between primary and secondary care: deficits and danger. August 21, 2019 Dinsdale E, Hannigan A, O’Connor R, et al. Communication between primary and secondary care: deficits and danger. Fam Pract. 2019;17(1):63-68. doi:10.1093/fampra/cmz037. https://psnet.ahrq.gov/issue/communication-between-primary…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43174/psn-pdf
    December 12, 2014 - Adverse drug event detection in pediatric oncology and hematology patients: using medication triggers to identify patient harm in a specialized pediatric patient population. December 12, 2014 Call RJ, Burlison JD, Robertson JJ, et al. Adverse drug event detection in pediatric oncology and hematology patients: usin…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47063/psn-pdf
    November 19, 2018 - I-PASS handoff program: use of a campaign to effect transformational change. November 19, 2018 Rosenbluth G, Destino LA, Starmer AJ, et al. I-PASS Handoff Program: Use of a Campaign to Effect Transformational Change. Ped Qual Saf. 2018;3(4):e088. doi:10.1097/pq9.0000000000000088. https://psnet.ahrq.gov/issue/i-pas…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39294/psn-pdf
    January 03, 2017 - Patient handoffs: standardized and reliable measurement tools remain elusive. January 3, 2017 Patterson ES, Wears RL. Patient handoffs: standardized and reliable measurement tools remain elusive. Jt Comm J Qual Patient Saf. 2010;36(2):52-61. https://psnet.ahrq.gov/issue/patient-handoffs-standardized-and-reliable-m…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46560/psn-pdf
    January 24, 2019 - The hidden cost of regulation: the administrative cost of reporting serious reportable events. January 24, 2019 Blanchfield BB, Acharya B, Mort E. The Hidden Cost of Regulation: The Administrative Cost of Reporting Serious Reportable Events. Jt Comm J Qual Patient Saf. 2018;44(4):212-218. doi:10.1016/j.jcjq.2017.0…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40236/psn-pdf
    March 23, 2012 - The safety implications of missed test results for hospitalised patients: a systematic review. March 23, 2012 Callen J, Georgiou A, Li J, et al. The safety implications of missed test results for hospitalised patients: a systematic review. BMJ Qual Saf. 2011;20(2):194-199. doi:10.1136/bmjqs.2010.044339. https://ps…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44542/psn-pdf
    December 22, 2018 - The prevalence of medical error related to end-of-life communication in Canadian hospitals: results of a multicentre observational study. December 22, 2018 Heyland DK, Ilan R, Jiang X, et al. The prevalence of medical error related to end-of-life communication in Canadian hospitals: results of a multicentre observ…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41775/psn-pdf
    December 18, 2014 - Measuring adverse events and levels of harm in pediatric inpatients with the Global Trigger Tool. December 18, 2014 Kirkendall E, Kloppenborg E, Papp J, et al. Measuring adverse events and levels of harm in pediatric inpatients with the Global Trigger Tool. Pediatrics. 2012;130(5):e1206-14. doi:10.1542/peds.2012-01…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43308/psn-pdf
    May 01, 2015 - An analysis of electronic health record–related patient safety concerns. May 1, 2015 Meeks DW, Smith MW, Taylor L, et al. An analysis of electronic health record-related patient safety concerns. J Am Med Inform Assoc. 2014;21(6):1053-9. doi:10.1136/amiajnl-2013-002578. https://psnet.ahrq.gov/issue/analysis-electro…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45101/psn-pdf
    July 01, 2017 - A systematic review of patient safety measures in adult primary care. July 1, 2017 Hatoun J, Chan J, Yaksic E, et al. A Systematic Review of Patient Safety Measures in Adult Primary Care. Am J Med Qual. 2017;32(3):237-245. doi:10.1177/1062860616644328. https://psnet.ahrq.gov/issue/systematic-review-patient-safety-…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45955/psn-pdf
    January 01, 2021 - The essential role of leadership in developing a safety culture. April 3, 2017 The essential role of leadership in developing a safety culture. Sentinel Event Alert. 2021;57(57):1-8. https://psnet.ahrq.gov/issue/essential-role-leadership-developing-safety-culture The Joint Commission issues sentinel event alerts t…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46807/psn-pdf
    July 02, 2019 - Communication failure: analysis of prescribers' use of an internal free-text field on electronic prescriptions. July 2, 2019 Ai A, Wong A, Amato MG, et al. Communication failure: analysis of prescribers’ use of an internal free-text field on electronic prescriptions. J Am Med Inform Assoc. 2018;25(6):709-714. doi:1…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44560/psn-pdf
    January 23, 2017 - What is the return on investment for implementation of a crew resource management program at an academic medical center? January 23, 2017 Moffatt-Bruce SD, Hefner JL, Mekhjian H, et al. What Is the Return on Investment for Implementation of a Crew Resource Management Program at an Academic Medical Center? Am J Med…