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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74006/psn-pdf
    October 27, 2021 - Building patient trust in hospitals: a combination of hospital-related factors and health care clinician behaviors. October 27, 2021 Greene J, Samuel-Jakubos H. Building patient trust in hospitals: a combination of hospital-related factors and health care clinician behaviors. Jt Comm J Qual Patient Saf. 2021;47(12…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43777/psn-pdf
    January 01, 2015 - Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams. December 17, 2014 Johnston MJ, King D, Arora S, et al. Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams. Am J Surg. 2015;209(1):45-51. doi:10.1016/j.amjsurg.2014.08.030.…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38060/psn-pdf
    April 11, 2011 - Iatrogenesis in neonatal intensive care units: observational and interventional, prospective, multicenter study. April 11, 2011 Kugelman A, Inbar-Sanado E, Shinwell ES, et al. Iatrogenesis in neonatal intensive care units: observational and interventional, prospective, multicenter study. Pediatrics. 2008;122(3):55…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44285/psn-pdf
    November 06, 2015 - Hospital board oversight of quality and safety: a stakeholder analysis exploring the role of trust and intelligence. November 6, 2015 Millar R, Freeman T, Mannion R. Hospital board oversight of quality and safety: a stakeholder analysis exploring the role of trust and intelligence. BMC Health Serv Res. 2015;15:196…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72607/psn-pdf
    December 23, 2020 - Defense Health Agency Processes for Responding to Provider Quality and Safety Concerns. December 23, 2020 Washington DC; Governmental Accountability Office; December 1, 2020. Publication GAO-21-160R. https://psnet.ahrq.gov/issue/defense-health-agency-processes-responding-provider-quality-and-safety- concerns Clin…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854387/psn-pdf
    October 11, 2023 - Healthcare resilience: a meta-narrative systematic review and synthesis of reviews. October 11, 2023 Tan MZY, Prager G, McClelland A, et al. Healthcare resilience: a meta-narrative systematic review and synthesis of reviews. BMJ Open. 2023;13(9):e072136. doi:10.1136/bmjopen-2023-072136. https://psnet.ahrq.gov/issu…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863002/psn-pdf
    February 21, 2024 - Three quarters of preventable patient harm stems from situation awareness breakdowns: recognizing and addressing the core issue. February 21, 2024 Tscholl DW, Hunn CA, Gasciauskaite G. APSF Newsletter. 2024;39:29–30. https://psnet.ahrq.gov/issue/three-quarters-preventable-patient-harm-stems-situation-awareness- b…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48075/psn-pdf
    June 19, 2019 - A mismatch made in America. June 19, 2019 Butcher L. Managed Care. June 2019;28:37-39. https://psnet.ahrq.gov/issue/mismatch-made-america Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient errors. This magazine article reports on the complex nature of addressing …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74042/psn-pdf
    November 03, 2021 - An Investigation into the Death of Baby J at University Hospitals Bristol and Weston NHS Foundation Trust. November 3, 2021 Manchester, UK: Parliamentary and Health Service Ombudsman; October 2021. https://psnet.ahrq.gov/issue/investigation-death-baby-j-university-hospitals-bristol-and-weston-nhs- foundation-trust…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840163/psn-pdf
    November 16, 2022 - Deep Dive: Racial and Ethnic Disparities in Health and Healthcare. November 16, 2022 Plymouth Meeting, PA: ECRI and the Institute for Safe Medication Practices; 2022. https://psnet.ahrq.gov/issue/deep-dive-racial-and-ethnic-disparities-health-and-healthcare Racist behavior directed at either patients or clinicians…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37909/psn-pdf
    February 23, 2009 - Prevalence of adverse drug combinations in a large post- mortem toxicology database. February 23, 2009 Launiainen T, Vuori E, Ojanperä I. Prevalence of adverse drug combinations in a large post-mortem toxicology database. Int J Legal Med. 2009;123(2):109-15. doi:10.1007/s00414-008-0261-3. https://psnet.ahrq.gov/is…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47801/psn-pdf
    May 11, 2019 - Opioid prescribing trends and the physician’s role in responding to the public health crisis. May 11, 2019 Adams JM, Giroir BP. Opioid Prescribing Trends and the Physician's Role in Responding to the Public Health Crisis. JAMA Intern Med. 2019;179(4):476-478. doi:10.1001/jamainternmed.2018.7934. https://psnet.ahrq…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45264/psn-pdf
    September 01, 2016 - Perceived factors associated with sustained improvement following participation in a multicenter quality improvement collaborative. September 1, 2016 Stone S, Lee HC, Sharek PJ. Perceived Factors Associated with Sustained Improvement Following Participation in a Multicenter Quality Improvement Collaborative. Jt Co…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837214/psn-pdf
    May 25, 2022 - Global Report on Infection Prevention and Control: Executive Summary. May 25, 2022 Geneva, Switzerland; World Health Organization; May 5, 2022. https://psnet.ahrq.gov/issue/global-report-infection-prevention-and-control-executive-summary Healthcare-acquired infection is a persistent systemic problem. This report r…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35069/psn-pdf
    June 22, 2009 - Towards an organization with a memory: exploring the organizational generation of adverse events in health care. June 22, 2009 Smith D, Toft B. Towards an organization with a memory: exploring the organizational generation of adverse events in health care. Health Serv Manage Res. 2005;18(2). doi:10.1258/0951484053…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43184/psn-pdf
    May 14, 2014 - Often overlooked problems with handoffs: from the intensive care unit to the operating room. May 14, 2014 Evans AS, Yee M-S, Hogue CW. Often overlooked problems with handoffs: from the intensive care unit to the operating room. Anesth Analg. 2014;118(3):687-9. doi:10.1213/ANE.0000000000000075. https://psnet.ahrq.g…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74015/psn-pdf
    October 27, 2021 - Safer Services: A Toolkit for Specialist Mental Health Services and Primary Care. October 27, 2021 National Confidential Inquiry into Suicide and Safety in Mental Health. Manchester, UK: University of Manchester; May 31, 2021 https://psnet.ahrq.gov/issue/safer-services-toolkit-specialist-mental-health-services-and…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34797/psn-pdf
    October 06, 2015 - Adapting to new technologies in the operating room. October 6, 2015 Cook RI, Woods DD. Adapting to New Technology in the Operating Room. Hum Factors. 2006;38(4):593- 613. doi:10.1518/001872096778827224. https://psnet.ahrq.gov/issue/adapting-new-technologies-operating-room New technology continues to offer great ad…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73429/psn-pdf
    June 23, 2021 - Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. June 23, 2021 Farnborough, UK: Healthcare Safety Investigation Branch; June 2021. https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings Wrong site/wrong patent surgery is a persisten…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43478/psn-pdf
    August 27, 2014 - Is it time to move beyond errors in clinical reasoning and discuss accuracy? August 27, 2014 Wood TJ. Is it time to move beyond errors in clinical reasoning and discuss accuracy? Adv Health Sci Educ Theory Pract. 2014;19(3):403-407. doi:10.1007/s10459-014-9498-4. https://psnet.ahrq.gov/issue/it-time-move-beyond-er…

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