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3601. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43371/psn-pdf
      June 19, 2019 - Medication Safety Officer's Handbook. June 19, 2019 Larson CM, Saine D, eds. Bethesda, MD: American Society of Health-System Pharmacists; 2013. ISBN: 9781585282104. https://psnet.ahrq.gov/issue/medication-safety-officers-handbook This book provides information about medication errors and quality improvement to gui…

3602. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45005/psn-pdf
      May 04, 2016 - Leading High-Reliability Organizations in Healthcare. May 4, 2016 Morrow R. Boca Raton, FL: Productivity Press; 2016. ISBN: 9781466594883. https://psnet.ahrq.gov/issue/leading-high-reliability-organizations-healthcare High reliability has been recently adopted as a goal for health care. This book reviews the primar…

3603. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851927/psn-pdf
      August 02, 2023 - Perioperative Handoffs. August 2, 2023 Abraham J, Rosen M, Greilich PE eds. Jt Comm J Qual Patient Saf. 2023;49(8):341-434. https://psnet.ahrq.gov/issue/perioperative-handoffs Handoffs occur several times during a surgical procedure, increasing the risk of communication mistakes and misunderstandings. This special…

3604. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73523/psn-pdf
      July 21, 2021 - TeamSTEPPS Video Toolkit. July 21, 2021 AHA Team Training and Project Firstline. Chicago, IL: American Hospital Association, Center for Disease Control and Prevention; July 2021. https://psnet.ahrq.gov/issue/teamstepps-video-toolkit Problems in communication are common contributors to patient care mistakes. This t…

3605. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44703/psn-pdf
      December 16, 2015 - Defining the Role of Social Sciences in Patient Safety. December 16, 2015 Su L, Fernandez R, Grand J, et al, eds. Curr Probl Pediatr Adolesc Health Care. 2015;45:365-394. https://psnet.ahrq.gov/issue/defining-role-social-sciences-patient-safety Applying principles from other fields, such as aviation and nuclear pow…

3606. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44503/psn-pdf
      November 18, 2024 - Certified Professional in Patient Safety Review Course. November 18, 2024 Institute for Healthcare Improvement. February 5-6, 2025, 12:00-4:00 PM (eastern). https://psnet.ahrq.gov/issue/certified-professional-patient-safety-review-course This online class prepares individuals to apply for the Institute for Healthca…

3607. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43322/psn-pdf
      January 28, 2015 - Patient Safety Initiative: Hospital Executive and Physician Leadership Strategies. January 28, 2015 Oakbrook, IL: Joint Commission Resources; January 2014. https://psnet.ahrq.gov/issue/patient-safety-initiative-hospital-executive-and-physician-leadership-strategies This toolkit draws from experiences of the Joint …

3608. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/845658/psn-pdf
      June 08, 2023 - Simulation Articles of Influence. June 8, 2023 Society for Simulation in Healthcare. 2017-2023. https://psnet.ahrq.gov/issue/simulation-articles-influence Simulation can be used to reveal teamwork coordination gaps and latent factors that contribute to failure. This article collection has been curated by experts i…

3609. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44553/psn-pdf
      October 07, 2015 - A medical detective story: why doctors make diagnostic errors. October 7, 2015 Landro L. Wall Street Journal. September 26, 2015. https://psnet.ahrq.gov/issue/medical-detective-story-why-doctors-make-diagnostic-errors In light of the recent IOM report on improving diagnosis, this newspaper article features an inte…

3610. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41668/psn-pdf
      December 21, 2014 - A surgical simulation curriculum for senior medical students based on TeamSTEPPS. December 21, 2014 Meier AH, Boehler ML, McDowell CM, et al. A surgical simulation curriculum for senior medical students based on TeamSTEPPS. Arch Surg. 2012;147(8):761-6. doi:10.1001/archsurg.2012.1340. https://psnet.ahrq.gov/issue/…

3611. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36148/psn-pdf
      March 03, 2011 - Surgical crisis management skills training and assessment: a stimulation-based approach to enhancing operating room performance. March 3, 2011 Moorthy K, Munz Y, Forrest D, et al. Surgical Crisis Management Skills Training and Assessment. Ann Surg. 2006;244(1). doi:10.1097/01.sla.0000217618.30744.61. https://psne…

3612. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47539/psn-pdf
      November 28, 2018 - The star of the diagnostic journey: assessing patient perspectives. November 28, 2018 Gipson K. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):39-45. https://psnet.ahrq.gov/issue/star-diagnostic-journey-assessing-patient-perspectives Patients are increasingly seen as partners in efforts to improve health ca…

3613. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50805/psn-pdf
      January 15, 2020 - Advancing safety with closed-loop communication of test results. January 15, 2020 Quick Safety. December 17, 2019;(52):1-3. https://psnet.ahrq.gov/issue/advancing-safety-closed-loop-communication-test-results Incomplete or delayed test result communication is a known factor in diagnostic error. This article shares…

3614. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41053/psn-pdf
      December 30, 2014 - Time to accelerate integration of human factors and ergonomics in patient safety. December 30, 2014 Gurses AP, Ozok A, Pronovost P. Time to accelerate integration of human factors and ergonomics in patient safety. BMJ Qual Saf. 2012;21(4):347-51. doi:10.1136/bmjqs-2011-000421. https://psnet.ahrq.gov/issue/time-acc…

3615. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46334/psn-pdf
      August 09, 2017 - Maternal deaths at MetroWest hospital prompt state probes. August 9, 2017 Kowalczyk L. Boston Globe. July 29, 2017. https://psnet.ahrq.gov/issue/maternal-deaths-metrowest-hospital-prompt-state-probes Maternal death is a sentinel event. This news article reports on two incidents at one hospital that prompted inves…

3616. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45793/psn-pdf
      July 19, 2024 - SHOT Annual Report. July 19, 2024 S Narayan, ed. Manchester, UK: Serious Hazards of Transfusion (SHOT) Steering Group; 2023. ISBN: 9781999596859. https://psnet.ahrq.gov/issue/shot-annual-report-2019 Although errors in the blood transfusion process are rare, they can be harmful. This annual report provides an anal…

3617. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46553/psn-pdf
      October 25, 2017 - Telehealth. October 25, 2017 Tuckson R, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med. 2017;377(16):1585-1592. doi:10.1056/NEJMsr1503323. https://psnet.ahrq.gov/issue/telehealth Telemedicine can improve patient experience and access to health care. This commentary reviews the current state of telehealth practi…

3618. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44770/psn-pdf
      September 24, 2016 - Obstacles to research on the effects of interruptions in healthcare. September 24, 2016 Grundgeiger T, Dekker SWA, Sanderson P, et al. Obstacles to research on the effects of interruptions in healthcare. BMJ Qual Saf. 2016;25(6):392-5. doi:10.1136/bmjqs-2015-004083. https://psnet.ahrq.gov/issue/obstacles-research-…

3619. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/860400/psn-pdf
      January 10, 2024 - AHA Patient Safety Initiative. January 10, 2024 American Hospital Association. https://psnet.ahrq.gov/issue/aha-patient-safety-initiative Leadership at the organization and system level is crucial to gaining improvement traction and sustainability. This initiative centers on safety culture, care inequities, and wo…

3620. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44155/psn-pdf
      June 24, 2015 - Patient Safety Tool Kit. June 24, 2015 WHO Regional Office for the Eastern Mediterranean. Cairo, Egypt: World Health Organization; 2015. ISBN: 9789290220596. https://psnet.ahrq.gov/issue/patient-safety-tool-kit Patient safety programs should reflect local needs, motivate clinician and leadership engagement, and s…