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1981. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35228/psn-pdf
      March 04, 2011 - Best practices for safe handling of products containing concentrated potassium. March 4, 2011 Tubman M, Majumdar SR, Lee D, et al. Best practices for safe handling of products containing concentrated potassium. BMJ. 2005;331(7511):274-7. https://psnet.ahrq.gov/issue/best-practices-safe-handling-products-containing…

1982. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44986/psn-pdf
      April 20, 2016 - Nurses' role in medical error recovery: an integrative review. April 20, 2016 Gaffney TA, Hatcher BJ, Milligan R. Nurses' role in medical error recovery: an integrative review. J Clin Nurs. 2016;25(7-8):906-17. doi:10.1111/jocn.13126. https://psnet.ahrq.gov/issue/nurses-role-medical-error-recovery-integrative-revi…

1983. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43462/psn-pdf
      September 12, 2016 - Preventable mortality after common urological surgery: failing to rescue? September 12, 2016 Sammon JD, Pucheril D, Abdollah F, et al. Preventable mortality after common urological surgery: failing to rescue? BJU Int. 2015;115(4):666-674. doi:10.1111/bju.12833. https://psnet.ahrq.gov/issue/preventable-mortality-af…

1984. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43171/psn-pdf
      May 14, 2014 - Fool me twice: delayed diagnoses in radiology with emphasis on perpetuated errors. May 14, 2014 Kim YW, Mansfield LT. Fool me twice: delayed diagnoses in radiology with emphasis on perpetuated errors. AJR Am J Roentgenol. 2014;202(3):465-70. doi:10.2214/AJR.13.11493. https://psnet.ahrq.gov/issue/fool-me-twice-dela…

1985. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838327/psn-pdf
      October 12, 2022 - Diagnoses Without Names: Challenges for Medical Care, Research, and Policy. October 12, 2022 Lockshin MD, Crow MK, Barbhaiya M, eds. Springer Nature: Cham, Switzerland; 2022.  ISBN 9783031049347.  https://psnet.ahrq.gov/issue/diagnoses-without-names-challenges-medical-care-research-and-policy Clinicians…

1986. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865597/psn-pdf
      April 17, 2024 - Discharge from Mental Health Care: Making it Safe and Patient-centred. April 17, 2024 Manchester, UK: Parliamentary and Health Service Ombudsman; March 2024. https://psnet.ahrq.gov/issue/discharge-mental-health-care-making-it-safe-and-patient-centred The provision of safe mental health care is receiving increased …

1987. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43813/psn-pdf
      January 20, 2015 - Adverse events in patients with return emergency department visits. January 20, 2015 Calder LA, Pozgay A, Riff S, et al. Adverse events in patients with return emergency department visits. BMJ Qual Saf. 2015;24(2):142-148. doi:10.1136/bmjqs-2014-003194. https://psnet.ahrq.gov/issue/adverse-events-patients-return-e…

1988. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61124/psn-pdf
      November 11, 2020 - Using Twitter to assess patient takes on patient experience. November 11, 2020 Heath S. Patient Engagement HIT. October 29, 2020. https://psnet.ahrq.gov/issue/using-twitter-assess-patient-takes-patient-experience Twitter is evolving as a useful data source for patient safety. This news story discusses an examinati…

1989. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38889/psn-pdf
      April 01, 2010 - Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation. April 1, 2010 Peute LW, Aarts J, Bakker PJM, et al. Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation. Int J Med Inform. 2010;79(4):e58-70. doi:…

1990. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47826/psn-pdf
      March 27, 2019 - Office-based surgery and patient outcomes. March 27, 2019 Young S, Shapiro FE, Urman RD. Office-based surgery and patient outcomes. Curr Opin Anaesthesiol. 2018;31(6):707-712. doi:10.1097/ACO.0000000000000655. https://psnet.ahrq.gov/issue/office-based-surgery-and-patient-outcomes Office-based surgery is increasing…

1991. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39676/psn-pdf
      February 01, 2011 - Patient empowerment and multimodal hand hygiene promotion: a win–win strategy. February 1, 2011 McGuckin M, Storr J, Longtin Y, et al. Patient empowerment and multimodal hand hygiene promotion: a win-win strategy. Am J Med Qual. 2011;26(1):10-7. doi:10.1177/1062860610373138. https://psnet.ahrq.gov/issue/patient-em…

1992. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866445/psn-pdf
      August 07, 2024 - Diagnosis in the Era of Digital Health and Artificial Intelligence: A Workshop. August 7, 2024 Diagnosis in the Era of Digital Health and Artificial Intelligence: A Workshop. https://psnet.ahrq.gov/issue/diagnosis-era-digital-health-and-artificial-intelligence-workshop Digital health is emerging as a primary techn…

1993. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38488/psn-pdf
      March 18, 2009 - Intensive care units, communication between nurses and physicians, and patients' outcomes. March 18, 2009 Manojlovich M, Antonakos CL, Ronis DL. Intensive care units, communication between nurses and physicians, and patients' outcomes. Am J Crit Care. 2009;18(1):21-30. doi:10.4037/ajcc2009353. https://psnet.ahrq.g…

1994. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43890/psn-pdf
      April 22, 2015 - Lack of timely follow-up of abnormal imaging results and radiologists' recommendations. April 22, 2015 Al-Mutairi A, Meyer AND, Chang P, et al. Lack of timely follow-up of abnormal imaging results and radiologists' recommendations. J Am Coll Radiol. 2015;12(4):385-389. doi:10.1016/j.jacr.2014.09.031. https://psnet…

1995. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73896/psn-pdf
      September 29, 2021 - Policies to promote shared responsibility for safer electronic health records. September 29, 2021 Sittig DF, Singh H. Policies to promote shared responsibility for safer electronic health records. JAMA. 2021;326(15):1477-1478. doi:10.1001/jama.2021.13945. https://psnet.ahrq.gov/issue/policies-promote-shared-respon…

1996. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/847550/psn-pdf
      April 12, 2023 - What's changed 1 year after RaDonda Vaught's conviction? April 12, 2023 Bean M, Carbajal E. Becker's Hospital Review. March 29, 2023. https://psnet.ahrq.gov/issue/whats-changed-1-year-after-radonda-vaughts-conviction The RaDonda Vaught conviction reverberated throughout health care and marked weaknesses in systems…

1997. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/855104/psn-pdf
      November 08, 2023 - Healthcare wants to fly as high as the aviation industry. Can it? November 8, 2023 Twenter P. Becker's Clinical Leadership. October 30, 2023. https://psnet.ahrq.gov/issue/healthcare-wants-fly-high-aviation-industry-can-it Health care has long held commercial aviation as a beacon to guide patient safety improv…

1998. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72686/psn-pdf
      January 27, 2021 - The Cognitive Autopsy: A Root Cause Analysis of Medical Decision Making. January 27, 2021 Croskerry P. New York, NY: Oxford University Press; 2020. ISBN: 9780190088743.  https://psnet.ahrq.gov/issue/cognitive-autopsy-root-cause-analysis-medical-decision-making Diagnostic error reduction methods are evolv…

1999. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42939/psn-pdf
      March 02, 2014 - Healthcare personnel attire in non–operating-room settings. March 2, 2014 Bearman G, Bryant K, Leekha S, et al. Healthcare personnel attire in non-operating-room settings. Infect Control Hosp Epidemiol. 2014;35(2):107-21. doi:10.1086/675066. https://psnet.ahrq.gov/issue/healthcare-personnel-attire-non-operating-ro…

2000. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73972/psn-pdf
      October 13, 2021 - The less-discussed consequence of healthcare's labor shortage. October 13, 2021 Bean M, Masson G. Becker's Hospital Review. October 4, 2021. https://psnet.ahrq.gov/issue/less-discussed-consequence-healthcares-labor-shortage Staffing shortages can impact the safety of care by enabling burnout, care omission, a…