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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847057/psn-pdf
    April 05, 2023 - Implement strategies to prevent persistent medication errors and hazards. April 5, 2023 ISMP Medication Safety Alert! Acute care edition. March 23, 2023;28(6):1-4. https://psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards Medication mistakes are recognized contributors to p…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73238/psn-pdf
    May 12, 2021 - Medical Residents and Burnout May 12, 2021 Coverdale J, West CP, Roberts LW, eds. Acad Med. 2021;96(5):611-769;e14-e21. https://psnet.ahrq.gov/issue/medical-residents-and-burnout Medical training is a demanding experience that impacts a learner’s ability to provide safe care, cope, and remain healthy. This is…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41438/psn-pdf
    January 03, 2017 - Implementing SBAR across a large multihospital health system. January 3, 2017 Compton J, Copeland K, Flanders S, et al. Implementing SBAR across a large multihospital health system. Jt Comm J Qual Patient Saf. 2012;38(6):261-8. https://psnet.ahrq.gov/issue/implementing-sbar-across-large-multihospital-health-system…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43252/psn-pdf
    August 24, 2016 - Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer. August 24, 2016 Zipperer L, ed. London, UK: Gower Publishing; 2014. ISBN: 9781409438571. https://psnet.ahrq.gov/issue/patient-safety-perspectives-evidence-information-and-knowledge-transfer This book provides information about utilizing …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854639/psn-pdf
    October 18, 2023 - Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive. October 18, 2023 Edmondson A. Atria Books, New York, 2023. ISBN: 9781982195069. https://psnet.ahrq.gov/issue/right-kind-wrong-why-learning-fail-can-teach-us-thrive Despite the harm that failure can cause, its value as a learning opportunity, if exam…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42633/psn-pdf
    October 02, 2013 - Health IT-Enabled Quality Measurement: Perspectives, Pathways, and Practical Guidance. October 2, 2013 Roper RA, Anderson KM, Marsh CA, Flemming AC. Rockville, MD: Agency for Healthcare Research and Quality; September 2013. AHRQ Publication No. 13-0059-EF.  https://psnet.ahrq.gov/issue/health-it-enabled-quali…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47485/psn-pdf
    January 09, 2019 - System-related and cognitive errors in laboratory medicine. January 9, 2019 Plebani M. System-related and cognitive errors in laboratory medicine. Diagnosis (Berl). 2018;5(4):191- 196. doi:10.1515/dx-2018-0085. https://psnet.ahrq.gov/issue/system-related-and-cognitive-errors-laboratory-medicine Problems managing …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43335/psn-pdf
    July 09, 2014 - Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. July 9, 2014 Tjia I, Rampersad S, Varughese AM, et al. Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. Anesth Analg. 2014;119(1):122-136. doi:10.1213/ANE.0000000000000266. https://psnet.ahrq.gov/is…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47734/psn-pdf
    March 13, 2019 - Medicare trims payments to 800 hospitals, citing patient safety incidents. March 13, 2019 Rau J. Kaiser Health News. March 1, 2019. https://psnet.ahrq.gov/issue/medicare-trims-payments-800-hospitals-citing-patient-safety-incidents Financial incentives may encourage adoption of practice improvements that enhance sa…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44488/psn-pdf
    September 16, 2015 - Environmental Cleaning for the Prevention of Healthcare- Associated Infections (HAIs). September 16, 2015 Leas BF, Sullivan N, Han JH, Pegues DA, Kaczmarek JL, Umscheid CA. Rockville, MD: Agency for Healthcare Research and Quality; August 2015. Technical Brief No. 22. AHRQ Publication No. 15- EHC020-EF. https://p…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45551/psn-pdf
    November 30, 2016 - Parents' perspectives on "keeping their children safe" in the hospital. November 30, 2016 Rosenberg RE, Rosenfeld P, Williams E, et al. Parents' Perspectives on "Keeping Their Children Safe" in the Hospital. J Nurs Care Qual. 2016;31(4):318-326. doi:10.1097/NCQ.0000000000000193. https://psnet.ahrq.gov/issue/parent…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46174/psn-pdf
    August 30, 2017 - Inpatients notes: sensemaking—fostering a shared understanding in clinical teams. August 30, 2017 Leykum LK, O'Leary KJ. Web Exclusives. Annals for Hospitalists Inpatient Notes - Sensemaking-Fostering a Shared Understanding in Clinical Teams. Ann Intern Med. 2017;167(4):HO2-HO3. doi:10.7326/M17- 1829. https://psn…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73354/psn-pdf
    June 02, 2021 - Advancing Maternal Health Equity and Reducing Maternal Mortality Workshop. June 2, 2021 National Academies of Sciences, Engineering, and Medicine. June 7-8, 2021. https://psnet.ahrq.gov/issue/advancing-maternal-health-equity-and-reducing-maternal-mortality-workshop Maternal safety is challenged by clinical, equity…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43458/psn-pdf
    August 27, 2014 - Validation of a teamwork perceptions measure to increase patient safety. August 27, 2014 Keebler JR, Dietz AS, Lazzara EH, et al. Validation of a teamwork perceptions measure to increase patient safety. BMJ Qual Saf. 2014;23(9):718-26. doi:10.1136/bmjqs-2013-001942. https://psnet.ahrq.gov/issue/validation-teamwork…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47749/psn-pdf
    June 19, 2019 - A simulation-based approach to training in heuristic clinical decision-making. June 19, 2019 Altabbaa G, Raven AD, Laberge J. A simulation-based approach to training in heuristic clinical decision- making. Diagnosis (Berl). 2019;6(2):91-99. doi:10.1515/dx-2018-0084. https://psnet.ahrq.gov/issue/simulation-based-ap…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47712/psn-pdf
    February 20, 2019 - A cognitive forcing tool to mitigate cognitive bias—a randomised control trial. February 20, 2019 O'Sullivan ED, Schofield SJ. A cognitive forcing tool to mitigate cognitive bias - a randomised control trial. BMC Med Educ. 2019;19(1):12. doi:10.1186/s12909-018-1444-3. https://psnet.ahrq.gov/issue/cognitive-forcing…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72686/psn-pdf
    January 27, 2021 - The Cognitive Autopsy: A Root Cause Analysis of Medical Decision Making. January 27, 2021 Croskerry P. New York, NY: Oxford University Press; 2020. ISBN: 9780190088743.  https://psnet.ahrq.gov/issue/cognitive-autopsy-root-cause-analysis-medical-decision-making Diagnostic error reduction methods are evolv…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41934/psn-pdf
    May 24, 2016 - Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on Medication Administration. May 24, 2016 Tucker AL. Cambridge, MA: Harvard Business School; November 19, 2012. (Revised September 2013). HBS Working Paper No. 13-044. https://psnet.ahrq.gov/issue/work-design-drive…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838639/psn-pdf
    October 19, 2022 - Calibrate Dx: A Resource to Improve Diagnostic Decisions. October 19, 2022 Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication no. 22(23)- 0047-2-EF. https://psnet.ahrq.gov/issue/calibrate-dx-resource-improve-diagnostic-decisions Delayed, wrong, and missed diagnoses are commo…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48182/psn-pdf
    August 21, 2019 - Organizational learning in hospitals: a realist review. August 21, 2019 Lyman B, Jacobs JD, Hammond EL, et al. Organizational learning in hospitals: A realist review. J Adv Nurs. 2019;75(11):2352-2377. doi:10.1111/jan.14091. https://psnet.ahrq.gov/issue/organizational-learning-hospitals-realist-review Organization…
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