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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46691/psn-pdf
    December 06, 2017 - Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns. December 6, 2017 Washington, DC: United States Government Accountability Office; November 2017. Publication GAO-18- 63. https://psnet.ahrq.gov/issue/improved-policies-and-oversight-needed-reviewing-and-rep…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45398/psn-pdf
    August 15, 2016 - Incorporating indications into medication ordering—time to enter the age of reason. August 15, 2016 Schiff G, Seoane-Vazquez E, Wright A. Incorporating Indications into Medication Ordering--Time to Enter the Age of Reason. N Engl J Med. 2016;375(4):306-9. doi:10.1056/NEJMp1603964. https://psnet.ahrq.gov/issue/inco…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44330/psn-pdf
    September 02, 2015 - Health Literacy: Past, Present, and Future: Workshop Summary. September 2, 2015 Alper J; Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of Medicine. Washington, DC: National Academies of Sciences, Engineering, and Medicine; 2015. ISBN: 9780309371544. https://psnet.…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43876/psn-pdf
    September 09, 2015 - Improving medication administration safety in a community hospital setting using Lean methodology. September 9, 2015 Critchley S. Improving medication administration safety in a community hospital setting using Lean methodology. J Nurs Care Qual. 2015;30(4):345-351. doi:10.1097/NCQ.0000000000000112. https://psnet.…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48140/psn-pdf
    July 31, 2019 - Impact of critical event checklists on anaesthetist performance in simulated operating theatre emergencies. July 31, 2019 Siddiqui A, Ng E, Burrows C, et al. Impact of Critical Event Checklists on Anaesthetist Performance in Simulated Operating Theatre Emergencies. Cureus. 2019;11(4):e4376. doi:10.7759/cureus.4376.…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44702/psn-pdf
    December 16, 2015 - Alarm fatigue: impacts on patient safety. December 16, 2015 Ruskin KJ, Hueske-Kraus D. Alarm fatigue: impacts on patient safety. Curr Opin Anaesthesiol. 2015;28(6):685-690. doi:10.1097/ACO.0000000000000260. https://psnet.ahrq.gov/issue/alarm-fatigue-impacts-patient-safety Alarm fatigue is a recognized safety conce…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44046/psn-pdf
    August 21, 2015 - Development of an instrument to measure the unintended consequences of EHRs. August 21, 2015 Carrington JM, Gephart SM, Verran JA, et al. Development of an Instrument to Measure the Unintended Consequences of EHRs. West J Nurs Res. 2015;37(7):842-58. doi:10.1177/0193945915576083. https://psnet.ahrq.gov/issue/devel…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42085/psn-pdf
    March 13, 2013 - In-facility delirium programs as a patient safety strategy: a systematic review. March 13, 2013 Reston JT, Schoelles KM. In-facility delirium prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):375-80. doi:10.7326/0003-4819-158-5-201303051-00003. https://psnet.ah…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44749/psn-pdf
    December 27, 2018 - Southern Baptist Hospital of Florida v. Charles. December 27, 2018 Fla Ct App, 1st Dist. October 28, 2015. https://psnet.ahrq.gov/issue/southern-baptist-hospital-florida-v-charles The Patient Safety and Quality Improvement Act (PSQIA) provides federal protection of adverse event reports voluntarily submitted to pa…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43976/psn-pdf
    November 16, 2015 - Multicenter development, implementation, and patient safety impacts of a simulation-based module to teach handovers to pediatric residents. November 16, 2015 Johnson DP, Zimmerman K, Staples B, et al. Multicenter development, implementation, and patient safety impacts of a simulation-based module to teach handover…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47101/psn-pdf
    December 21, 2018 - Education and reporting of diagnostic errors among physicians in internal medicine training programs. December 21, 2018 Wijesekera TP, Sanders L, Windish DM. Education and Reporting of Diagnostic Errors Among Physicians in Internal Medicine Training Programs. JAMA Intern Med. 2018;178(11):1548-1549. doi:10.1001/ja…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45785/psn-pdf
    September 29, 2017 - Traditions of research into interruptions in healthcare: a conceptual review. September 29, 2017 McCurdie T, Sanderson P, Aitken LM. Traditions of research into interruptions in healthcare: A conceptual review. Int J Nurs Stud. 2017;66:23-36. doi:10.1016/j.ijnurstu.2016.11.005. https://psnet.ahrq.gov/issue/traditi…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44055/psn-pdf
    April 15, 2015 - Health Care Simulation to Advance Safety: Responding to Ebola and Other Threats. April 15, 2015 Rockville, MD: Agency for Healthcare Research and Quality; February 2015. AHRQ Publication No. 15- 0021. https://psnet.ahrq.gov/issue/health-care-simulation-advance-safety-responding-ebola-and-other-threats Simulation …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46476/psn-pdf
    October 04, 2017 - The effectiveness of nurse education and training for clinical alarm response and management: a systematic review. October 4, 2017 Yue L, Plummer V, Cross W. The effectiveness of nurse education and training for clinical alarm response and management: a systematic review. J Clin Nurs. 2017;26(17-18):2511-2526. doi…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36511/psn-pdf
    January 07, 2011 - Facing ambiguous threats. January 7, 2011 Roberto MA, Bohmer RMJ, Edmondson A. Facing ambiguous threats. Harv Bus Rev. 2006;84(11):106-13, 157. https://psnet.ahrq.gov/issue/facing-ambiguous-threats This study describes how organizations respond to signs that may or may not portend future catastrophes. The authors…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45010/psn-pdf
    March 30, 2016 - Most dangerous time at the hospital? It may be when you leave. March 30, 2016 Khullar D. New York Times. March 17, 2016. https://psnet.ahrq.gov/issue/most-dangerous-time-hospital-it-may-be-when-you-leave Preventing readmissions after hospital discharge is a national policy priority. This newspaper article discuss…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44024/psn-pdf
    October 13, 2015 - Cultivating a culture of medication safety in prelicensure nursing students. October 13, 2015 Bush PA, Hueckel RM, Robinson D, et al. Cultivating a Culture of Medication Safety in Prelicensure Nursing Students. Nurse Educ. 2015;40(4):169-73. doi:10.1097/NNE.0000000000000148. https://psnet.ahrq.gov/issue/cultivatin…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45263/psn-pdf
    September 04, 2016 - PSYCH: a mnemonic to help psychiatric residents decrease patient handoff communication errors. September 4, 2016 Mariano MT, Brooks V, DiGiacomo M. PSYCH: A Mnemonic to Help Psychiatric Residents Decrease Patient Handoff Communication Errors. Jt Comm J Qual Patient Saf. 2016;42(7):316-320. https://psnet.ahrq.gov/i…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47076/psn-pdf
    August 15, 2018 - Incident learning in radiation oncology: a review. August 15, 2018 Ford E, Evans SB. Incident learning in radiation oncology: A review. Med Phys. 2018;45(5):e100-e119. doi:10.1002/mp.12800. https://psnet.ahrq.gov/issue/incident-learning-radiation-oncology-review Learning from adverse events is a core component of …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41917/psn-pdf
    May 04, 2022 - ISMP Guidelines for Sterile Compounding and the Safe Use of Sterile Compounding Technology. May 4, 2022 Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022. https://psnet.ahrq.gov/issue/ismp-guidelines-sterile-compounding-and-safe-use-sterile-compounding- technology This updated report describes b…
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