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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48102/psn-pdf
    August 07, 2019 - The unmeasured quality metric: burn out and the second victim syndrome in healthcare. August 7, 2019 Heiss K, Clifton M. The unmeasured quality metric: Burn out and the second victim syndrome in healthcare. Semin Pediatr Surg. 2019;28(3):189-194. doi:10.1053/j.sempedsurg.2019.04.011. https://psnet.ahrq.gov/issue/u…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47064/psn-pdf
    August 22, 2018 - Lax oversight leaves surgery center regulators and patients in the dark. August 22, 2018 Jewett C, Alesia M. Kaiser Health News. August 9, 2018. https://psnet.ahrq.gov/issue/lax-oversight-leaves-surgery-center-regulators-and-patients-dark High-profile failures during office-based procedures have raised awareness o…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45716/psn-pdf
    September 29, 2017 - Microanalysis of video from the operating room: an underused approach to patient safety research. September 29, 2017 Bezemer J, Cope A, Korkiakangas T, et al. Microanalysis of video from the operating room: an underused approach to patient safety research. BMJ Qual Saf. 2017;26(7):583-587. doi:10.1136/bmjqs-2016-00…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46786/psn-pdf
    May 30, 2018 - Improving patient safety for older people in acute admissions: implementation of the Frailsafe checklist in 12 hospitals across the UK. May 30, 2018 Papoutsi C, Poots A, Clements J, et al. Improving patient safety for older people in acute admissions: implementation of the Frailsafe checklist in 12 hospitals acros…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44080/psn-pdf
    September 27, 2017 - A descriptive study of nurse-reported missed care in neonatal intensive care units. September 27, 2017 Tubbs-Cooley HL, Pickler RH, Younger JB, et al. A descriptive study of nurse-reported missed care in neonatal intensive care units. J Adv Nurs. 2015;71(4):813-24. doi:10.1111/jan.12578. https://psnet.ahrq.gov/iss…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44735/psn-pdf
    January 06, 2016 - Quality and patient safety teams in the perioperative setting. January 6, 2016 Serino MF. Quality and Patient Safety Teams in the Perioperative Setting. AORN J. 2015;102(6):617-28. doi:10.1016/j.aorn.2015.10.006. https://psnet.ahrq.gov/issue/quality-and-patient-safety-teams-perioperative-setting Team effectivenes…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45271/psn-pdf
    August 10, 2016 - Patient identification and tube labelling—a call for harmonisation. August 10, 2016 van Dongen-Lases EC, Cornes MP, Grankvist K, et al. Patient identification and tube labelling – a call for harmonisation. Clinical Chemistry and Laboratory Medicine (CCLM). 2016;54(7). doi:10.1515/cclm-2015- 1089. https://psnet.ah…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44439/psn-pdf
    September 16, 2015 - Color-coded prefilled medication syringes decrease time to delivery and dosing errors in simulated prehospital pediatric resuscitations: a randomized crossover trial. September 16, 2015 Stevens AD, Hernandez C, Jones S, et al. Color-coded prefilled medication syringes decrease time to delivery and dosing errors in…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44348/psn-pdf
    September 04, 2016 - Examining the attitudes of hospital pharmacists to reporting medication safety incidents using the theory of planned behaviour. September 4, 2016 Williams SD, Phipps D, Ashcroft DM. Examining the attitudes of hospital pharmacists to reporting medication safety incidents using the theory of planned behaviour. Int J…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73170/psn-pdf
    April 21, 2021 - Sentinel Event Alert 63: optimizing smart infusion pump safety with DERS. April 21, 2021 Sentinel Event Alert 63: Optimizing Smart Infusion Pump Safety with DERS. Jt Comm J Qual Patient Saf. 2021;47(6):394-397. doi:10.1016/j.jcjq.2021.03.013. https://psnet.ahrq.gov/issue/sentinel-event-alert-63-optimizing-smart-in…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74721/psn-pdf
    February 02, 2022 - Hospital at Home: setting a regulatory course to ensure safe, high-quality care. February 2, 2022 DeCherrie LV, Leff B, Levine DM, et al. Hospital at Home: setting a regulatory course to ensure safe, high- quality care. Jt Comm J Qual Patient Saf. 2022;48(3):180-184. doi:10.1016/j.jcjq.2021.12.003. https://psnet.a…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44836/psn-pdf
    January 27, 2016 - Advancing the next generation of handover research and practice with cognitive load theory. January 27, 2016 Young JQ, Wachter R, Cate OT, et al. Advancing the next generation of handover research and practice with cognitive load theory. BMJ Qual Saf. 2016;25(2):66-70. doi:10.1136/bmjqs-2015-004181. https://psnet.…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840167/psn-pdf
    November 16, 2022 - 'Reading the Signals' : Maternity and Neonatal Services in East Kent – the Report of the Independent Investigation. November 16, 2022 Kirkup B. Department of Health and Social Care. London, England: Crown Copyright; 2022.  ISBN: 9781528636759. https://psnet.ahrq.gov/issue/reading-signals-maternity-and-neonata…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44943/psn-pdf
    April 15, 2016 - Evaluation of frequency of paediatric oral liquid medication dosing errors by caregivers: amoxicillin and josamycin. April 15, 2016 Berthe-Aucejo A, Girard D, Lorrot M, et al. Evaluation of frequency of paediatric oral liquid medication dosing errors by caregivers: amoxicillin and josamycin. Arch Dis Child. 2016;1…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47724/psn-pdf
    March 20, 2019 - Understanding patient safety and quality outcome data. March 20, 2019 Easter K, Tamburri LM. Understanding Patient Safety and Quality Outcome Data. Crit Care Nurse. 2018;38(6):58-66. doi:10.4037/ccn2018979. https://psnet.ahrq.gov/issue/understanding-patient-safety-and-quality-outcome-data Public reporting of safet…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73575/psn-pdf
    August 04, 2021 - Unlocking Solutions in Imaging: Working Together to Learn from Failings in the NHS. August 4, 2021 Manchester, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016.  https://psnet.ahrq.gov/issue/unlocking-solutions-imaging-working-together-learn-failings-nhs Lack of appropriate follow up o…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47205/psn-pdf
    July 25, 2018 - Teamwork and Teamwork Training in Healthcare. July 25, 2018 Teamwork and Teamwork Training in Health care: An Integration and a Path Forward. Buljac-Samardzic M, Dekker-van Doorn C, Maynard MT, eds. Group Org Manag. 2018;43(3):351-527. doi:10.1177/1059601118774669. https://psnet.ahrq.gov/issue/teamwork-and-teamwor…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45073/psn-pdf
    May 11, 2016 - Promoting patient safety: results of a TeamSTEPPS initiative. May 11, 2016 Gaston T, Short N, Ralyea C, et al. Promoting patient safety: results of a TeamSTEPPS initiative. J Nurs Adm. 2016;46(4):201-207. doi:10.1097/nna.0000000000000333. https://psnet.ahrq.gov/issue/promoting-patient-safety-results-teamstepps-ini…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846761/psn-pdf
    September 29, 2018 - Using clinical simulation to study how to improve quality and safety in healthcare. September 29, 2018 Lamé G, Dixon-Woods M. Using clinical simulation to study how to improve quality and safety in healthcare. BMJ Simul Technol Enhanc Learn. 2018;6(2):87-94. doi:10.1136/bmjstel-2018-000370. https://psnet.ahrq.gov/…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46131/psn-pdf
    December 19, 2017 - Characteristics associated with requests by pathologists for second opinions on breast biopsies. December 19, 2017 Geller BM, Nelson HD, Weaver DL, et al. Characteristics associated with requests by pathologists for second opinions on breast biopsies. J Clin Pathol. 2017;70(11):947-953. doi:10.1136/jclinpath-2016- …