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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44274/psn-pdf
    February 18, 2019 - Concepts for the development of a customizable checklist for use by patients. February 18, 2019 Fernando RJ, Shapiro FE, Rosenberg NM, et al. Concepts for the Development of a Customizable Checklist for Use by Patients. J Patient Saf. 2019;15(1):18-23. doi:10.1097/PTS.0000000000000203. https://psnet.ahrq.gov/issue…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46838/psn-pdf
    March 07, 2018 - Behavioral & Mental Health Toolbox. March 7, 2018 Center for Health Design. Concord, CA: Center for Health Design; 2018. https://psnet.ahrq.gov/issue/behavioral-mental-health-toolbox Behavioral and mental health patients have unique concerns that affect their safety. This toolkit provides strategies, insights, and…

  3. 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 …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43825/psn-pdf
    January 28, 2015 - A systematic review of adult admissions to ICUs related to adverse drug events. January 28, 2015 Jolivot P-A, Hindlet P, Pichereau C, et al. A systematic review of adult admissions to ICUs related to adverse drug events. Crit Care. 2014;18(6):643. doi:10.1186/s13054-014-0643-5. https://psnet.ahrq.gov/issue/systema…

  5. 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…

  6. 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…

  7. 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…

  8. 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…

  9. 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…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44606/psn-pdf
    October 28, 2015 - 'Trust but verify'—five approaches to ensure safe medical apps. October 28, 2015 Wicks P, Chiauzzi E. 'Trust but verify'--five approaches to ensure safe medical apps. BMC Med. 2015;13:205. doi:10.1186/s12916-015-0451-z. https://psnet.ahrq.gov/issue/trust-verify-five-approaches-ensure-safe-medical-apps Mobile heal…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73692/psn-pdf
    September 08, 2021 - Quality and safety in surgery: challenges and opportunities. September 8, 2021 Nasca BJ, Bilimoria KY, Yang AD. Quality and safety in surgery: challenges and opportunities. Jt Comm J Qual Patient Saf. 2021;47(9):604-607. doi:10.1016/j.jcjq.2021.05.003. https://psnet.ahrq.gov/issue/quality-and-safety-surgery-challe…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45756/psn-pdf
    December 21, 2016 - Accidental IV infusion of heparinized irrigation in the OR. December 21, 2016 ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3. https://psnet.ahrq.gov/issue/accidental-iv-infusion-heparinized-irrigation-or Accidental administration of irrigation solutions are a wrong-route error that can re…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42564/psn-pdf
    September 11, 2013 - Error rating tool to identify and analyse technical errors and events in laparoscopic surgery. September 11, 2013 Bonrath EM, Zevin B, Dedy NJ, et al. Error rating tool to identify and analyse technical errors and events in laparoscopic surgery. Br J Surg. 2013;100(8):1080-8. doi:10.1002/bjs.9168. https://psnet.ah…

  14. 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…

  15. 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…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838638/psn-pdf
    September 01, 2012 - Directed peer review in surgical pathology. September 1, 2012 Smith ML, Raab SS. Directed peer review in surgical pathology. Adv Anat Pathol. 2012;19(5):331-337. doi:10.1097/pap.0b013e31826661b7. https://psnet.ahrq.gov/issue/directed-peer-review-surgical-pathology Diagnostic error in pathology can result in delaye…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50580/psn-pdf
    October 23, 2019 - Suspicious insulin injections, nearly a dozen deaths: inside an unfolding investigation at a VA hospital in West Virginia. October 23, 2019 Rein L. Washington Post. October 5, 2019. https://psnet.ahrq.gov/issue/suspicious-insulin-injections-nearly-dozen-deaths-inside-unfolding- investigation-va-hospital The Vete…

  18. 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…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853980/psn-pdf
    September 27, 2023 - RFID tags reduce restocking errors of anesthesia medications. September 27, 2023 Banks MA. Specialty Pharmacy Continuum. September 15, 2023. https://psnet.ahrq.gov/issue/rfid-tags-reduce-restocking-errors-anesthesia-medications Radiofrequency identification (RFID) devices are being used to improve processes in the…

  20. Understanding CAHPS® Surveys: A Primer for New Users - Closing (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-ask-question-webinar.pdf
    June 02, 2025 - Understanding CAHPS® Surveys: A Primer for New Users - Closing www.ahrq.gov/cahps To Ask a Question Click on the “Q&A” icon to get the Q&A window to appear. 48 To submit a question, type your question here and hit submit. www.ahrq.gov/cahps Wrap-Up • Complete the evaluation survey at the end of the Webcas…
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