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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37849/psn-pdf
    March 23, 2011 - The incidence and nature of in-hospital adverse events: a systematic review. March 23, 2011 de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008;17(3):216-223. doi:10.1136/qshc.2007.023622. https://psnet.ahrq.gov/is…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37091/psn-pdf
    March 02, 2016 - The tension between needing to improve care and knowing how to do it. March 2, 2016 Auerbach AD, Landefeld S, Shojania KG. The tension between needing to improve care and knowing how to do it. N Engl J Med. 2007;357(6):608-13. https://psnet.ahrq.gov/issue/tension-between-needing-improve-care-and-knowing-how-do-it …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40921/psn-pdf
    November 16, 2011 - Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events. November 16, 2011 Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; October 2011. Report No. OEI-01-08-00590. https://psnet.ahrq.gov/issue/adverse-events-hospitals-medicares-response…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36455/psn-pdf
    December 22, 2010 - Changing the work environment in ICUs to achieve patient-focused care: the time has come. December 22, 2010 McCauley K, Irwin RS. Changing the work environment in ICUs to achieve patient-focused care: the time has come. Chest. 2006;130(5):1571-8. https://psnet.ahrq.gov/issue/changing-work-environment-icus-achieve-…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60017/psn-pdf
    March 04, 2020 - Changes in cancer detection and false-positive recall in mammography using artificial intelligence: a retrospective, multireader study. March 4, 2020 Kim H-E, Kim HH, Han B-K, et al. Changes in cancer detection and false-positive recall in mammography using artificial intelligence: a retrospective, multireader stu…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/839816/psn-pdf
    January 01, 2023 - Gender bias in risk management reports involving physicians in training - a retrospective qualitative study. November 9, 2022 Andraska EA, Phillips AR, Asaadi S, et al. Gender bias in risk management reports involving physicians in training - a retrospective qualitative study. J Surg Educ. 2023;80(1):102-109. doi:…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866312/psn-pdf
    July 17, 2024 - Development of patient safety measures to identify inappropriate diagnosis of common infections. July 17, 2024 White AT, Vaughn VM, Petty LA, et al. Development of patient safety measures to identify inappropriate diagnosis of common infections. Clin Infect Dis. 2024;78(6):1403-1411. doi:10.1093/cid/ciae044. https…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866517/psn-pdf
    August 14, 2024 - Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. August 14, 2024 Aikens RC, Chen JH, Baiocchi M, et al. Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. Med Decis Making. 2024;44(5):481-496. doi:10.1177/0272989x241248612. https://p…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50573/psn-pdf
    October 23, 2019 - Preventing patient harm via adverse event review: An APSA survey regarding the role of morbidity and mortality (M&M) conference. October 23, 2019 Berman L, Ottosen M, Renaud E, et al. Preventing patient harm via adverse event review: An APSA survey regarding the role of morbidity and mortality (M&M) conference. J …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848318/psn-pdf
    May 03, 2023 - Teamwork, clinical leadership skills and environmental factors that influence missed nursing care - a qualitative study on hospital wards. May 3, 2023 Beiboer C, Andela R, Hafsteinsdóttir TB, et al. Teamwork, clinical leadership skills and environmental factors that influence missed nursing care – a qualitative st…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38935/psn-pdf
    March 01, 2017 - Leadership committed to safety. December 23, 2016 Sentinel Event Alert. August 27, 2009;(43):1-3. https://psnet.ahrq.gov/issue/leadership-committed-safety Despite the past decade's focus on improving patient safety, most health care organizations are still striving to achieve high reliability status—consistently p…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837799/psn-pdf
    August 10, 2022 - Effect of a pharmacy-based centralized intravenous admixture service on the prevalence of medication errors: a before-and-after study. August 10, 2022 Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. Effect of a pharmacy-based centralized intravenous admixture service on the prevalence of medication errors: a befo…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837069/psn-pdf
    January 01, 2024 - Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and implementation. May 11, 2022 Salwei ME, Hoonakker PLT, Carayon P, et al. Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33901/psn-pdf
    August 01, 2023 - Patient Safety Indicators Overview. August 1, 2023 Agency for Healthcare Research and Quality https://psnet.ahrq.gov/issue/patient-safety-indicators-overview The AHRQ Patient Safety Indicators (PSIs) represent quality measures that make use of a hospital's available administrative data. The PSIs reflect the qualit…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73132/psn-pdf
    April 14, 2021 - Association of clinician diagnostic performance with machine learning–based decision support systems: a systematic review. April 14, 2021 Vasey B, Ursprung S, Beddoe B, et al. Association of clinician diagnostic performance with machine learning–based decision support systems: a systematic review. JAMA Netw Open. …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39358/psn-pdf
    October 13, 2010 - Hospital safety climate and safety outcomes: is there a relationship in the VA? October 13, 2010 Rosen AK, Singer SJ, Zhao S, et al. Hospital safety climate and safety outcomes: is there a relationship in the VA? Med Care Res Rev. 2010;67(5):590-608. doi:10.1177/1077558709356703. https://psnet.ahrq.gov/issue/hospi…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46309/psn-pdf
    December 22, 2018 - Effects of the I-PASS nursing handoff bundle on communication quality and workflow. December 22, 2018 Starmer AJ, Schnock KO, Lyons A, et al. Effects of the I-PASS Nursing Handoff Bundle on communication quality and workflow. BMJ Qual Saf. 2017;26(12):949-957. doi:10.1136/bmjqs-2016-006224. https://psnet.ahrq.gov/…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36518/psn-pdf
    March 28, 2011 - Nurses' attitudes to a medical emergency team service in a teaching hospital. March 28, 2011 Jones D, Baldwin I, McIntyre T, et al. Nurses' attitudes to a medical emergency team service in a teaching hospital. Qual Saf Health Care. 2006;15(6):427-32. https://psnet.ahrq.gov/issue/nurses-attitudes-medical-emergency-…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866687/psn-pdf
    September 11, 2024 - An exploratory analysis of the association between healthcare associated infections & hospital financial performance. September 11, 2024 Beauvais B, Dolezel D, Shanmugam R, et al. An exploratory analysis of the association between healthcare associated infections & hospital financial performance. Healthcare (Basel…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41494/psn-pdf
    June 27, 2012 - National Voluntary Consensus Standards for Patient Safety Measures: A Consensus Report. June 27, 2012 Washington, DC: National Quality Forum; June 2012. https://psnet.ahrq.gov/issue/national-voluntary-consensus-standards-patient-safety-measures-consensus- report Progress in improving patient safety has been hampe…

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