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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/74009/psn-pdf
    October 27, 2021 - Quantifying discharge medication reconciliation errors at 2 pediatric hospitals. October 27, 2021 Morse KE, Chadwick WA, Paul W, et al. Quantifying discharge medication reconciliation errors at 2 pediatric hospitals. Pediatr Qual Saf. 2021;6(4):e436. doi:10.1097/pq9.0000000000000436. https://psnet.ahrq.gov/issue/q…

  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/35966/psn-pdf
    January 02, 2017 - Assessing and monitoring override medications in automated dispensing devices. January 2, 2017 Kowiatek JG, Weber RJ, Skledar S, et al. Assessing and monitoring override medications in automated dispensing devices. Jt Comm J Qual Patient Saf. 2006;32(6):309-17. https://psnet.ahrq.gov/issue/assessing-and-monitoring…

  14. 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…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60989/psn-pdf
    October 07, 2020 - The accuracy of preliminary diagnoses made by paramedics - a cross-sectional comparative study. October 7, 2020 Koivulahti O, Tommila M, Haavisto E. The accuracy of preliminary diagnoses made by paramedics – a cross-sectional comparative study. Scand J Trauma Resusc Emerg Med. 2020;28(1):70. doi:10.1186/s13049-020…

  16. 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…

  17. 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…

  18. 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…

  19. 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…

  20. 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…
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