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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72601/psn-pdf
    January 01, 2021 - Increasing physician reporting of diagnostic learning opportunities. December 23, 2020 Marshall TL, Ipsaro AJ, Le M, et al. Increasing physician reporting of diagnostic learning opportunities. Pediatrics. 2021;147(1):e20192400. doi:10.1542/peds.2019-2400. https://psnet.ahrq.gov/issue/increasing-physician-reporting…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44999/psn-pdf
    August 03, 2017 - An analysis of electronic health record–related patient safety incidents. August 3, 2017 Palojoki S, Mäkelä M, Lehtonen L, et al. An analysis of electronic health record-related patient safety incidents. Health Informatics J. 2017;23(2):134-145. doi:10.1177/1460458216631072. https://psnet.ahrq.gov/issue/analysis-e…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40527/psn-pdf
    June 15, 2011 - Online medication error graphic reports: a pilot in North Carolina nursing homes. June 15, 2011 Greene SB, Williams CE, Pierson S, et al. Online medication error graphic reports: a pilot in North Carolina nursing homes. J Patient Saf. 2011;7(2):92-8. doi:10.1097/PTS.0b013e31821b4eab. https://psnet.ahrq.gov/issue/o…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/858173/psn-pdf
    December 13, 2023 - Measurement of ambulatory medication errors in children: a scoping review. December 13, 2023 Rickey L, Auger K, Britto MT, et al. Measurement of ambulatory medication errors in children: a scoping review. Pediatrics. 2023;152(6):e2023061281. doi:10.1542/peds.2023-061281. https://psnet.ahrq.gov/issue/measurement-am…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72581/psn-pdf
    December 16, 2020 - Dispensing Errors. December 16, 2020 Phipps D, Ashour A, Riste L, et al. The Pharmaceutical Journal. 2020;305(7943, 7944). November 10, December 1, 2020. https://psnet.ahrq.gov/issue/dispensing-errors Dispensing mistakes are a common contributor to preventable adverse events in community pharmacies. Par…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46726/psn-pdf
    January 31, 2018 - Toolkit to Promote Safe Surgery. January 31, 2018 Rockville, MD: Agency for Healthcare Research and Quality; November 2017. https://psnet.ahrq.gov/issue/toolkit-promote-safe-surgery Preventing surgical complications including surgical site infections are a worldwide target for improvement. This toolkit builds on t…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42031/psn-pdf
    February 06, 2013 - Assessing diagnostic reasoning: a consensus statement summarizing theory, practice, and future needs. February 6, 2013 Ilgen JS, Humbert AJ, Kuhn G, et al. Assessing diagnostic reasoning: a consensus statement summarizing theory, practice, and future needs. Acad Emerg Med. 2012;19(12):1454-61. doi:10.1111/acem.1203…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45363/psn-pdf
    September 14, 2016 - Effective perioperative communication to enhance patient care. September 14, 2016 Garrett H. Effective Perioperative Communication to Enhance Patient Care. AORN J. 2016;104(2):111-20. doi:10.1016/j.aorn.2016.06.001. https://psnet.ahrq.gov/issue/effective-perioperative-communication-enhance-patient-care Poor team …

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46367/psn-pdf
    August 30, 2017 - Why are so many women being misdiagnosed? August 30, 2017 Mickle K. Glamour. August 11, 2017. https://psnet.ahrq.gov/issue/why-are-so-many-women-being-misdiagnosed Implicit bias and differences in communication style can affect patient care. This magazine article reports on factors that contribute to misdiagnosis …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44718/psn-pdf
    November 25, 2015 - Beyond the Quick Fix: Strategies for Improving Patient Safety. November 25, 2015 Baker GR. Toronto, ON: Institute of Health Policy, Management and Evaluation, University of Toronto; 2015. https://psnet.ahrq.gov/issue/beyond-quick-fix-strategies-improving-patient-safety The 2004 Canadian Adverse Events Study helpe…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44229/psn-pdf
    October 13, 2015 - Patterns and predictors of medication discrepancies in primary care. October 13, 2015 Coletti DJ, Stephanou H, Mazzola N, et al. Patterns and predictors of medication discrepancies in primary care. J Eval Clin Pract. 2015;21(5):831-9. doi:10.1111/jep.12387. https://psnet.ahrq.gov/issue/patterns-and-predictors-medi…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39876/psn-pdf
    July 02, 2014 - The anatomy of health care team training and the state of practice: a critical review. July 2, 2014 Weaver SJ, Lyons R, DiazGranados D, et al. The anatomy of health care team training and the state of practice: a critical review. Acad Med. 2010;85(11):1746-60. doi:10.1097/ACM.0b013e3181f2e907. https://psnet.ahrq.g…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843323/psn-pdf
    February 01, 2023 - Long-Term Trends of Psychotropic Drug Use in Nursing Homes. February 1, 2023 Grimm CA. Washington DC: Office of the Inspector General; Nov 2022. Report no. OEI-07-20- 00500. https://psnet.ahrq.gov/issue/long-term-trends-psychotropic-drug-use-nursing-homes Misdiagnosis can result in inappropriate medication u…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39295/psn-pdf
    January 03, 2017 - The Veterans Affairs shift change physician-to-physician handoff project. January 3, 2017 Anderson J, Shroff D, Curtis A, et al. The Veterans Affairs shift change physician-to-physician handoff project. Jt Comm J Qual Patient Saf. 2010;36(2):62-71. https://psnet.ahrq.gov/issue/veterans-affairs-shift-change-physici…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41012/psn-pdf
    December 29, 2014 - The impact of patient and public involvement on UK NHS health care: a systematic review. December 29, 2014 Mockford C, Staniszewska S, Griffiths F, et al. The impact of patient and public involvement on UK NHS health care: a systematic review. Int J Qual Health Care. 2012;24(1):28-38. doi:10.1093/intqhc/mzr066. ht…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60945/psn-pdf
    September 23, 2020 - Safety in pediatric hospice and palliative care: a qualitative study. September 23, 2020 Pestian T, Thienprayoon R, Grossoehme D, et al. Safety in pediatric hospice and palliative care: a qualitative study. Pediatr Qual Saf. 2020;5(4):e328. doi:10.1097/pq9.0000000000000328. https://psnet.ahrq.gov/issue/safety-pedi…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46698/psn-pdf
    February 07, 2018 - Enhancing the quality and safety of the perioperative patient. February 7, 2018 Staender S, Smith A. Enhancing the quality and safety of the perioperative patient. Curr Opin Anaesthesiol. 2017;30(6):730-735. doi:10.1097/ACO.0000000000000517. https://psnet.ahrq.gov/issue/enhancing-quality-and-safety-perioperative-p…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44910/psn-pdf
    March 09, 2016 - Systematically Identified Failure Is the Route to a Successful Health System. March 9, 2016 Tepper J, Martin D, eds. Healthc Pap. 2015;15(2):4-61. https://psnet.ahrq.gov/issue/systematically-identified-failure-route-successful-health-system Identifying and addressing organizational factors that enable individual m…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47268/psn-pdf
    May 11, 2019 - Measuring shared mental models in healthcare. May 11, 2019 Gisick LM, Webster KL, Keebler JR, et al. J Patient Saf Risk Manag. 2018;23:207–219. https://psnet.ahrq.gov/issue/measuring-shared-mental-models-healthcare Shared mental models are an important element of team collaboration. This review explores the current…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39268/psn-pdf
    April 01, 2010 - Multi-professional patterns and methods of communication during patient handoffs. April 1, 2010 Benham-Hutchins MM, Effken JA. Multi-professional patterns and methods of communication during patient handoffs. Int J Med Inform. 2010;79(4):252-67. doi:10.1016/j.ijmedinf.2009.12.005. https://psnet.ahrq.gov/issue/mult…
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