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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48141/psn-pdf
    July 24, 2019 - Evidence Brief: Implementation of High Reliability Organization Principles. July 24, 2019 Veazie S, Peterson K, Bourne D. Washington DC: United States Department of Veterans Affairs; May 2019. https://psnet.ahrq.gov/issue/evidence-brief-implementation-high-reliability-organization-principles This brief evalu…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855437/psn-pdf
    November 15, 2023 - Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief. November 15, 2023 National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937. https://psnet.ahrq.gov/issue/advancing-diagnostic-excellence-maternal-h…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44794/psn-pdf
    May 21, 2019 - Medical Device Use Error: Root Cause Analysis. May 21, 2019 Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790. https://psnet.ahrq.gov/issue/medical-device-use-error-root-cause-analysis Applying human factors engineering to examine mistakes associated with medical device use can lead …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44674/psn-pdf
    December 18, 2017 - Achieving Safe Health Care: Delivery of Safe Patient Care at Baylor Scott & White Health. December 18, 2017 Compton J. Boca Raton, FL: CRC Press; 2016. ISBN: 9781498732390. https://psnet.ahrq.gov/issue/achieving-safe-health-care-delivery-safe-patient-care-baylor-scott-white-health Since the publication of the Inst…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46609/psn-pdf
    January 01, 2020 - The impact of adverse events on clinicians: what's in a name? April 3, 2019 Wu AW, Shapiro J, Harrison R, et al. The Impact of Adverse Events on Clinicians: What's in a Name? J Patient Saf. 2020;16(1):65-72. doi:10.1097/PTS.0000000000000256. https://psnet.ahrq.gov/issue/impact-adverse-events-clinicians-whats-name …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50827/psn-pdf
    January 22, 2020 - Becoming a high-reliability organization through shared learning of safety events January 22, 2020 Klenklen J. Patient Saf Qual HCare. December 19, 2019. https://psnet.ahrq.gov/issue/becoming-high-reliability-organization-through-shared-learning-safety-events High reliability organizations consistently examine wha…
  7. psnet.ahrq.gov/web-mm/dropped-lung
    February 06, 2012 - The Dropped Lung Citation Text: Heffner JR. The Dropped Lung. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840175/psn-pdf
    November 16, 2022 - Mechanical Prosthetic Valve Thrombosis with Thromboembolism. November 16, 2022 Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism The Case A 61-year-old woman presented to …
  9. psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
    September 27, 2023 - SPOTLIGHT CASE Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations Citation Text: Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. PSNet [internet]. Agency for Healthcare Research and Qu…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47168/psn-pdf
    April 27, 2019 - Balancing patient-centered and safe pain care for nonsurgical inpatients: clinical and managerial perspectives. April 27, 2019 Mazurenko O, Andraka-Christou BT, Bair MJ, et al. Balancing Patient-Centered and Safe Pain Care for Nonsurgical Inpatients: Clinical and Managerial Perspectives. Jt Comm J Qual Patient Saf…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846755/psn-pdf
    March 29, 2023 - Reducing diagnostic errors in the emergency department at the time of patient treatment. March 29, 2023 Petts A, Neep M, Thakkalpalli M. Reducing diagnostic errors in the emergency department at the time of patient treatment. Emerg Med Australas. 2023;35(3):466-473. doi:10.1111/1742-6723.14146. https://psnet.ahrq.…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844059/psn-pdf
    February 08, 2023 - Misdiagnosis in the emergency department: time for a system solution. February 8, 2023 Edlow JA, Pronovost PJ. Misdiagnosis in the emergency department: time for a system solution. JAMA. 2023;329(8):631-632. doi:10.1001/jama.2023.0577. https://psnet.ahrq.gov/issue/misdiagnosis-emergency-department-time-system-solu…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850175/psn-pdf
    June 07, 2023 - Explicitly addressing implicit bias on inpatient rounds: student and faculty reflections. June 7, 2023 Carter RG, Lake S. Explicitly addressing implicit bias on inpatient rounds: student and faculty reflections. Pediatrics. 2023;151(5). doi:10.1542/peds.2023-061585. https://psnet.ahrq.gov/issue/explicitly-addressi…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836986/psn-pdf
    April 27, 2022 - Habit and automaticity in medical alert override: cohort study. April 27, 2022 Wang L, Goh KH, Yeow A, et al. Habit and automaticity in medical alert override: cohort study. J Med Internet Res. 2022;24(2):e23355. doi:10.2196/23355. https://psnet.ahrq.gov/issue/habit-and-automaticity-medical-alert-override-cohort-s…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865702/psn-pdf
    May 01, 2024 - Judgment errors in surgical care. May 1, 2024 Marsh KM, Turrentine FE, Jin R, et al. Judgment errors in surgical care. J Am Coll Surg. 2024;238(5):874- 879. doi:10.1097/xcs.0000000000001011. https://psnet.ahrq.gov/issue/judgment-errors-surgical-care Knowing when judgment errors are more likely to occur can increas…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45886/psn-pdf
    July 05, 2017 - Organizational perspectives of nurse executives in 15 hospitals on the impact and effectiveness of rapid response teams. July 5, 2017 Smith PL, McSweeney J. Organizational Perspectives of Nurse Executives in 15 Hospitals on the Impact and Effectiveness of Rapid Response Teams. Jt Comm J Qual Patient Saf. 2017;43(6…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45485/psn-pdf
    July 01, 2017 - Psychological responses, coping and supporting needs of healthcare professionals as second victims. July 1, 2017 Chan ST, Khong PCB, Wang W. Psychological responses, coping and supporting needs of healthcare professionals as second victims. Intern Nurs Rev. 2017;64(2):242-262. doi:10.1111/inr.12317. https://psnet.…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863210/psn-pdf
    February 28, 2024 - Disparities in racial, ethnic, and payer groups for pediatric safety events in US hospitals. February 28, 2024 Parikh K, Hall M, Tieder JS, et al. Disparities in racial, ethnic, and payer groups for pediatric safety events in US hospitals. Pediatrics. 2024;153(3):e2023063714. doi:10.1542/peds.2023-063714. https://…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44924/psn-pdf
    April 15, 2016 - Assessment of fidelity in interventions to improve hand hygiene of healthcare workers: a systematic review. April 15, 2016 Musuuza JS, Barker A, Ngam C, et al. Assessment of Fidelity in Interventions to Improve Hand Hygiene of Healthcare Workers: A Systematic Review. Infect Control Hosp Epidemiol. 2016;37(5):567-75…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44235/psn-pdf
    January 22, 2016 - Interventions to reduce nurses' medication administration errors in inpatient settings: a systematic review and meta- analysis. January 22, 2016 Berdot S, Roudot M, Schramm C, et al. Interventions to reduce nurses' medication administration errors in inpatient settings: A systematic review and meta-analysis. Int J…

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