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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47765/psn-pdf
    February 20, 2019 - Negative behaviours in health care: prevalence and strategies. February 20, 2019 Layne DM, Nemeth LS, Mueller M, et al. Negative behaviours in health care: Prevalence and strategies. J Nurs Manag. 2019;27(1):154-160. doi:10.1111/jonm.12660. https://psnet.ahrq.gov/issue/negative-behaviours-health-care-prevalence-an…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44467/psn-pdf
    February 20, 2016 - The underappreciated role of habit in highly reliable healthcare. February 20, 2016 Vogus TJ, Hilligoss B. The underappreciated role of habit in highly reliable healthcare. BMJ Qual Saf. 2016;25(3):141-6. doi:10.1136/bmjqs-2015-004512. https://psnet.ahrq.gov/issue/underappreciated-role-habit-highly-reliable-health…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44452/psn-pdf
    September 04, 2016 - Reflecting on diagnostic errors: taking a second look is not enough. September 4, 2016 Monteiro SD, Sherbino J, Patel A, et al. Reflecting on Diagnostic Errors: Taking a Second Look is Not Enough. J Gen Intern Med. 2015;30(9):1270-4. doi:10.1007/s11606-015-3369-4. https://psnet.ahrq.gov/issue/reflecting-diagnostic…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38451/psn-pdf
    March 23, 2011 - Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems. March 23, 2011 Braithwaite J, Runciman WB, Merry AF. Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems. Qual Saf Health Care. 2009;18(1):37-41. doi:10.1136/qshc…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41926/psn-pdf
    January 02, 2013 - As she lay dying: how I fought to stop medical errors from killing my mom. January 2, 2013 Welch JR. As she lay dying: how I fought to stop medical errors from killing my mom. Health Aff (Millwood). 2012;31(12):2817-2820. doi:10.1377/hlthaff.2012.0833. https://psnet.ahrq.gov/issue/she-lay-dying-how-i-fought-stop-m…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44939/psn-pdf
    March 09, 2016 - Listening for What Matters: Avoiding Contextual Errors in Health Care. March 9, 2016 Weiner SJ, Schwartz A. New York, NY: Oxford University Press; 2016. ISBN: 9780190228996. https://psnet.ahrq.gov/issue/listening-what-matters-avoiding-contextual-errors-health-care This book discusses how physicians can reduce cont…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39966/psn-pdf
    February 01, 2011 - Journey to no preventable risk: The Baylor Health Care System patient safety experience. February 1, 2011 Kennerly DA, Richter KM, Good V, et al. Journey to no preventable risk: the Baylor Health Care System patient safety experience. Am J Med Qual. 2011;26(1):43-52. doi:10.1177/1062860610374645. https://psnet.ahr…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46875/psn-pdf
    March 07, 2018 - Improving medication-related clinical decision support. March 7, 2018 Tolley CL, Slight SP, Husband AK, et al. Improving medication-related clinical decision support. Am J Health Syst Pharm. 2018;75(4):239-246. doi:10.2146/ajhp160830. https://psnet.ahrq.gov/issue/improving-medication-related-clinical-decision-suppo…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36946/psn-pdf
    September 09, 2011 - The Patient Safety Leadership Academy at the University of Pennsylvania: the first cohort's learning experience. September 9, 2011 Wurster AB, Pearson K, Sonnad SS, et al. The Patient Safety Leadership Academy at the University of Pennsylvania: the first cohort's learning experience. Qual Manag Health Care. 2007;16…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42306/psn-pdf
    May 29, 2013 - Do team processes really have an effect on clinical performance? A systematic literature review. May 29, 2013 Schmutz J, Manser T. Do team processes really have an effect on clinical performance? A systematic literature review. Br J Anaesth. 2013;110(4). doi:10.1093/bja/aes513. https://psnet.ahrq.gov/issue/do-team…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39796/psn-pdf
    July 09, 2013 - Selecting Quality and Resource Use Measures: A Decision Guide for Community Quality Collaboratives. July 9, 2013 Romano PS, Hussey P, Ritley D. Rockville, MD: Agency for Healthcare Research and Quality; 2010. AHRQ Publication No. 09(10)-0073. https://psnet.ahrq.gov/issue/selecting-quality-and-resource-use-measures…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39554/psn-pdf
    October 13, 2010 - Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions. October 13, 2010 Bernstein J, MacCourt DC, Jacob DM, et al. Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions. Clin Orthop Relat Res. 2010;468(10):2627-32.…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44240/psn-pdf
    June 23, 2015 - Risks are high at low-volume hospitals. June 23, 2015 Sternberg S; Dougherty G. https://psnet.ahrq.gov/issue/risks-are-high-low-volume-hospitals This news article reports an independent analysis of patient risk at hospitals that provide surgeries they infrequently perform, highlighting how high procedure volume an…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841197/psn-pdf
    December 07, 2022 - Does malpractice liability promote patient safety? A methodological excursion. December 7, 2022 Saks MJ, Landsman S. Jurimetrics. 2022;62:397-419. https://psnet.ahrq.gov/issue/does-malpractice-liability-promote-patient-safety-methodological-excursion Malpractice liability is an unconfirmed driver for safety. This …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45229/psn-pdf
    July 13, 2016 - The WakeWings journey: creating a patient safety program. July 13, 2016 Mills E. The WakeWings Journey: Creating a Patient Safety Program. AORN J. 2016;103(6):636-9. doi:10.1016/j.aorn.2016.04.004. https://psnet.ahrq.gov/issue/wakewings-journey-creating-patient-safety-program Successful and sustainable implementa…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37272/psn-pdf
    December 23, 2011 - Communication techniques for patients with low health literacy: a survey of physicians, nurses, and pharmacists. December 23, 2011 Schwartzberg JG, Cowett A, VanGeest J, et al. Communication techniques for patients with low health literacy: a survey of physicians, nurses, and pharmacists. Am J Health Behav. 2007;31…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36811/psn-pdf
    August 26, 2011 - Expanded surgical time out: a key to real-time data collection and quality improvement. August 26, 2011 Altpeter T, Luckhardt K, Lewis JN, et al. Expanded surgical time out: a key to real-time data collection and quality improvement. J Am Coll Surg. 2007;204(4):527-32. https://psnet.ahrq.gov/issue/expanded-surgica…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837746/psn-pdf
    July 27, 2022 - Oxford Professional Practice: Handbook of Patient Safety. July 27, 2022 Lachman P, Runnacles J, Jayadev A et al, eds. London, England; Oxford University Press; 2022. ISBN: 9780192846877. https://psnet.ahrq.gov/issue/oxford-professional-practice-handbook-patient-safety Patient safety needs to routinely involve new …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46593/psn-pdf
    November 08, 2017 - Unreadable barcodes and multiple barcodes on packages can lead to errors. November 8, 2017 ISMP Medication Safety Alert! Acute care edition. October 19, 2017;22:1-3. https://psnet.ahrq.gov/issue/unreadable-barcodes-and-multiple-barcodes-packages-can-lead-errors Barcodes can both enhance and degrade the medication …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845079/psn-pdf
    February 22, 2023 - Pump up the volume: how to prioritize events and analyze error data. February 22, 2023 ISMP Medication Safety Alert! Acute care edition. February 9, 2023;28(3):1-4. https://psnet.ahrq.gov/issue/pump-volume-how-prioritize-events-and-analyze-error-data Patient safety event reporting is an established component of a …
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