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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73639/psn-pdf
    August 25, 2021 - The Safety of Maternity Services in England. August 25, 2021 Fourth Report of Session 2021–22. House of Commons Health Committee. London, England: The Stationery Office; July 6, 2021. Publication HC 19.  https://psnet.ahrq.gov/issue/safety-maternity-services-england High-profile failures motivate examination …

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40070/psn-pdf
    December 08, 2010 - Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine. December 8, 2010 Thyen AB, McAllister RK, Councilman LM. Epidural Pump Programming Error Leading to Inadvertent 10- Fold Dosing Error During Epidural Labor Analgesia With Ropivacaine. J Pat…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45547/psn-pdf
    October 05, 2016 - Sick children face potentially deadly danger: medication errors. October 5, 2016 Furfaro H. Wall Street Journal. September 25, 2016. https://psnet.ahrq.gov/issue/sick-children-face-potentially-deadly-danger-medication-errors Medication errors in pediatric care are common in the hospital and at home. This newspaper…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42913/psn-pdf
    January 29, 2014 - What to do with healthcare incident reporting systems. January 29, 2014 Pham JC, Girard T, Pronovost PJ. What to do with healthcare Incident Reporting Systems. J Public Health Res. 2013;2(3). doi:10.4081/jphr.2013.e27. https://psnet.ahrq.gov/issue/what-do-healthcare-incident-reporting-systems Incident reporting sy…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44714/psn-pdf
    November 25, 2015 - Continuous Improvement of Patient Safety: The Case for Change in the NHS. November 25, 2015 Illingworth J. London, UK: The Health Foundation; 2015. ISBN: 9781906461706. https://psnet.ahrq.gov/issue/continuous-improvement-patient-safety-case-change-nhs The Francis inquiry uncovered problems in the National Health S…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41802/psn-pdf
    October 31, 2012 - Relationship between high-fidelity simulation and patient safety in prelicensure nursing education: a comprehensive review. October 31, 2012 Blum CA, Parcells DA. Relationship between high-fidelity simulation and patient safety in prelicensure nursing education: a comprehensive review. J Nurs Educ. 2012;51(8):429-…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47597/psn-pdf
    August 07, 2019 - Intentional rounding—an integrative literature review. August 7, 2019 Ryan L, Jackson D, Woods C, et al. Intentional rounding - An integrative literature review. J Adv Nurs. 2019;75(6):1151-1161. doi:10.1111/jan.13897. https://psnet.ahrq.gov/issue/intentional-rounding-integrative-literature-review This review exam…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44660/psn-pdf
    December 02, 2015 - The SQUIRE Guidelines: an evaluation from the field, 5 years post release. December 2, 2015 Davies L, Batalden P, Davidoff F, et al. The SQUIRE Guidelines: an evaluation from the field, 5 years post release. BMJ Qual Saf. 2015;24(12):769-75. doi:10.1136/bmjqs-2015-004116. https://psnet.ahrq.gov/issue/squire-guidel…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47358/psn-pdf
    August 29, 2018 - Double reading in breast cancer screening: cohort evaluation in the CO-OPS trial. August 29, 2018 Taylor-Phillips S, Jenkinson D, Stinton C, et al. Double Reading in Breast Cancer Screening: Cohort Evaluation in the CO-OPS Trial. Radiology. 2018;287(3):749-757. doi:10.1148/radiol.2018171010. https://psnet.ahrq.gov…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60766/psn-pdf
    August 05, 2020 - Dermatology faces a reckoning: lack of darker skin in textbooks and journals harms care for patients of color. August 5, 2020 McFarling UL. Stat. July 21, 2020. https://psnet.ahrq.gov/issue/dermatology-faces-reckoning-lack-darker-skin-textbooks-and-journals-harms- care-patients-color Dermatologists rely on v…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45581/psn-pdf
    October 19, 2016 - Reducing diagnostic errors. October 19, 2016 Gittlen S. HealthLeaders Media. October 1, 2016. https://psnet.ahrq.gov/issue/reducing-diagnostic-errors-0 The recent recognition of diagnostic error as a blind spot in health care has driven the need to enhance diagnosis. This news article reports how health systems, a…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846168/psn-pdf
    March 15, 2023 - Now is the time to routinely ask patients about safety. March 15, 2023 Gandhi TK. Now Is the Time to Routinely Ask Patients About Safety. Jt Comm J Qual Patient Saf. 2023;49(4):235-236. doi:10.1016/j.jcjq.2023.01.009. https://psnet.ahrq.gov/issue/now-time-routinely-ask-patients-about-safety Safety event reporting …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43677/psn-pdf
    November 19, 2014 - Reporting and Learning Systems for Medication Errors: The Role of Pharmacovigilance Centres. November 19, 2014 Bencheikh SR, Cousins D, Benabdallah G, et al. Geneva, Switzerland: World Health Organization; October 2014. ISBN: 9789241507943. https://psnet.ahrq.gov/issue/reporting-and-learning-systems-medication-err…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46161/psn-pdf
    May 31, 2017 - Developing team cognition: a role for simulation. May 31, 2017 Fernandez R, Shah S, Rosenman ED, et al. Developing Team Cognition. Simul Healthc. 2017;12(2):96- 103. doi:10.1097/sih.0000000000000200. https://psnet.ahrq.gov/issue/developing-team-cognition-role-simulation Simulation training has been advocated as a …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47414/psn-pdf
    May 01, 2019 - Impact of teamwork improvement training on communication and teamwork climate in ambulatory reproductive health care. May 1, 2019 Dodge LE, Nippita S, Hacker MR, et al. Impact of teamwork improvement training on communication and teamwork climate in ambulatory reproductive health care. J Healthc Risk Manag. 2019;3…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35556/psn-pdf
    May 27, 2011 - Improving patient safety using interactive, evidence- based decision support tools. May 27, 2011 Quinn MM, Mannion J. Improving patient safety using interactive, evidence-based decision support tools. Jt Comm J Qual Patient Saf. 2005;31(12):678-683. https://psnet.ahrq.gov/issue/improving-patient-safety-using-inter…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46458/psn-pdf
    May 30, 2018 - Development of the Huddle Observation Tool for structured case management discussions to improve situation awareness on inpatient clinical wards. May 30, 2018 Edbrooke-Childs J, Hayes J, Sharples E, et al. Development of the Huddle Observation Tool for structured case management discussions to improve situation aw…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47540/psn-pdf
    April 03, 2019 - Medication handling: towards a practical, human-centred approach. April 3, 2019 Marshall SD, Chrimes N. Medication handling: towards a practical, human-centred approach. Anaesthesia. 2019;74(3):280-284. doi:10.1111/anae.14482. https://psnet.ahrq.gov/issue/medication-handling-towards-practical-human-centred-approac…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43082/psn-pdf
    April 16, 2014 - Improving code team performance and survival outcomes: implementation of pediatric resuscitation team training. April 16, 2014 Knight LJ, Gabhart JM, Earnest KS, et al. Improving code team performance and survival outcomes: implementation of pediatric resuscitation team training. Crit Care Med. 2014;42(2):243-251.…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44889/psn-pdf
    April 13, 2017 - An organizational learning framework for patient safety. April 13, 2017 Edwards MT. An Organizational Learning Framework for Patient Safety. Am J Med Qual. 2016;32(2):148- 155. doi:10.1177/1062860616632295. https://psnet.ahrq.gov/issue/organizational-learning-framework-patient-safety Organizations are encouraged t…
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