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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42415/psn-pdf
    July 24, 2013 - Strategies for improving communication in the emergency department: mediums and messages in a noisy environment. July 24, 2013 Welch SJ, Cheung DS, Apker J, et al. Strategies for improving communication in the emergency department: mediums and messages in a noisy environment. Jt Comm J Qual Patient Saf. 2013;39(6)…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43961/psn-pdf
    August 02, 2015 - Reducing inappropriate polypharmacy: the process of deprescribing. August 2, 2015 Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827-34. doi:10.1001/jamainternmed.2015.0324. https://psnet.ahrq.gov/issue/reducing-inappropriate-pol…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45526/psn-pdf
    January 01, 2019 - Improving incident reporting among physician trainees. September 28, 2016 Krouss M, Alshaikh J, Croft LD, et al. Improving Incident Reporting Among Physician Trainees. J Patient Saf. 2019;15(4):308-310. doi:10.1097/PTS.0000000000000325. https://psnet.ahrq.gov/issue/improving-incident-reporting-among-physician-train…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44270/psn-pdf
    July 01, 2015 - Improving Patient Safety Culture Through Teamwork and Communication: TeamSTEPPS. July 1, 2015 Chicago, IL: Health Research & Educational Trust; June 2015. https://psnet.ahrq.gov/issue/improving-patient-safety-culture-through-teamwork-and-communication- teamstepps This guide draws from the experience of organizati…
  5. 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…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43123/psn-pdf
    August 04, 2015 - Redesigning surgical decision making for high-risk patients. August 4, 2015 Glance LG, Osler T, Neuman MD. Redesigning surgical decision making for high-risk patients. N Engl J Med. 2014;370(15):1379-1381. doi:10.1056/NEJMp1315538. https://psnet.ahrq.gov/issue/redesigning-surgical-decision-making-high-risk-patient…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44495/psn-pdf
    September 30, 2015 - Impact of laws aimed at healthcare-associated infection reduction: a qualitative study. September 30, 2015 Stone PW, Pogorzelska-Maziarz M, Reagan J, et al. Impact of laws aimed at healthcare-associated infection reduction: a qualitative study. BMJ Qual Saf. 2015;24(10):637-44. doi:10.1136/bmjqs-2014- 003921. htt…
  8. 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 …
  9. 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…
  10. 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 …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72583/psn-pdf
    December 16, 2020 - Wear face masks with no metal during MRI exams. December 16, 2020 FDA Safety Communication. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 7, 2020. https://psnet.ahrq.gov/issue/wear-face-masks-no-metal-during-mri-exams Magnetic resonance imaging (MRI) requires patient prep…
  12. 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…
  13. 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…
  14. 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…
  15. 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…
  16. 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…
  17. 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…
  18. 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…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40670/psn-pdf
    August 03, 2011 - ED revamp: team approach to care reduces errors, boosts patient and clinician satisfaction. August 3, 2011 ED revamp: team approach to care reduces errors, boosts patient and clinician satisfaction. ED management : the monthly update on emergency department management. 2011;23(7):78-80. https://psnet.ahrq.gov/issu…
  20. 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…