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3101. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72512/psn-pdf
      November 25, 2020 - The untold story of a cyberattack, a hospital and a dying woman. November 25, 2020 Ralston W. Wired Magazine. November 11, 2020. https://psnet.ahrq.gov/issue/untold-story-cyberattack-hospital-and-dying-woman Health information system downtime can affect patient safety. This story discusses a ransomware incide…

3102. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74766/psn-pdf
      June 24, 2024 - Patient handoffs. June 24, 2024 Arora V, Farnan J. UpToDate. June 24, 2024. https://psnet.ahrq.gov/issue/patient-handoffs-0 The change of an inpatient’s location or handoffs between teams can fragment care due to communication, information, and knowledge gaps. This review examines in-patient transition safety issu…

3103. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37242/psn-pdf
      September 12, 2016 - Failure-to-rescue: comparing definitions to measure quality of care. September 12, 2016 Silber JH, Romano PS, Rosen AK, et al. Failure-to-rescue: comparing definitions to measure quality of care. Med Care. 2007;45(10):918-25. https://psnet.ahrq.gov/issue/failure-rescue-comparing-definitions-measure-quality-care T…

3104. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837813/psn-pdf
      January 21, 2021 - Recognizing Excellence in Diagnosis. January 21, 2021 The Leapfrog Group. https://psnet.ahrq.gov/issue/recognizing-excellence-diagnosis Examination of diagnostic failure and identification of reduction strategies require multidisciplinary expertise to be successful. This collaborative initiative will initially dev…

3105. Avera Health | Digital Healthcare Research
      digital.ahrq.gov/organization/avera-health
      January 01, 2023 - Avera Health Electronic Prescribing and Decision Support to Improve Rural Primary Care Quality - 2011 Principal Investigator Veline, James Project Name Electronic Prescribing and Decision Support to Improve Rural Primary Care Quality Elect…

3106. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35133/psn-pdf
      March 11, 2011 - Parents as partners in obtaining the medication history. March 11, 2011 Porter SC, Kohane IS, Goldmann DA. Parents as partners in obtaining the medication history. J Am Med Inform Assoc. 2005;12(3):299-305. https://psnet.ahrq.gov/issue/parents-partners-obtaining-medication-history This study examined the utility o…

3107. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42603/psn-pdf
      March 04, 2015 - Cognitive and system factors contributing to diagnostic errors in radiology. March 4, 2015 Lee CS, Nagy PG, Weaver SJ, et al. Cognitive and system factors contributing to diagnostic errors in radiology. AJR Am J Roentgenol. 2013;201(3):611-7. doi:10.2214/AJR.12.10375. https://psnet.ahrq.gov/issue/cognitive-and-sys…

3108. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37039/psn-pdf
      September 14, 2007 - Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards of Directors. September 14, 2007 Callender AN, Hastings DA, Hemsley MC, et al. Washington DC: Office of the Inspector General of the US Department of Health and Human Services, American Health Lawyers Association; September 2007. h…

3109. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37568/psn-pdf
      February 03, 2011 - Survival from in-hospital cardiac arrest during nights and weekends. February 3, 2011 Peberdy MA, Ornato JP, Larkin L, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA. 2008;299(7):785-92. doi:10.1001/jama.299.7.785. https://psnet.ahrq.gov/issue/survival-hospital-cardiac-arrest-duri…

3110. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853443/psn-pdf
      September 13, 2023 - Complications and Errors in Periodontal and Implant Therapy. September 13, 2023 Zucchelli G, Stefanini M, eds. Periodontol 2000. 2023;92(1):1-398. https://psnet.ahrq.gov/issue/complications-and-errors-periodontal-and-implant-therapy Patient safety in dentistry shares common challenges with medicine and t…

3111. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853626/psn-pdf
      September 20, 2023 - Uncovering the shocking dangers of misdiagnosis. September 20, 2023 Graedon T. People’s Pharmacy.  Show 1355. September 8, 2023. https://psnet.ahrq.gov/issue/uncovering-shocking-dangers-misdiagnosis Misdiagnosis continues to impact the safety of health care. This podcast with David Newman-Toker discusses foun…

3112. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73690/psn-pdf
      September 08, 2021 - Medicine's Shadowside: Revisiting Clinical Iatrogenesis. September 8, 2021 Varley E, Varma S, eds. Anthropol Med. 2021;28(2);141-278.   https://psnet.ahrq.gov/issue/medicines-shadowside-revisiting-clinical-iatrogenesis Implicit biases are rooted in culture and context. This special issue examine…

3113. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865820/psn-pdf
      May 08, 2024 - Breaking the silence on medical mistakes. May 8, 2024 Scott M. The Pulse. New York Public Radio; April 26, 2024. https://psnet.ahrq.gov/issue/breaking-silence-medical-mistakes Individuals involved in medical errors need time and support to process the incident and its consequences. This moderated podcast examines …

3114. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/861779/psn-pdf
      January 31, 2024 - Health Care Equity January 31, 2024 Jt Comm J Qual Patient Saf. 2024;50(1);1-92. https://psnet.ahrq.gov/issue/health-care-equity Health care inequities are the result of both clinical and community system failures. This special issue highlights activities in the field that examine investigative methods to better u…

3115. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39246/psn-pdf
      April 11, 2018 - How perioperative nurses define, attribute causes of, and react to intraoperative nursing errors. April 11, 2018 Chard R. How perioperative nurses define, attribute causes of, and react to intraoperative nursing errors. AORN J. 2010;91(1):132-45. doi:10.1016/j.aorn.2009.06.028. https://psnet.ahrq.gov/issue/how-per…

3116. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50920/psn-pdf
      February 19, 2020 - Preeminent hospitals penalized over rates of patients’ injuries. February 19, 2020 Rau J. Kaiser Health News. January 30, 2020. https://psnet.ahrq.gov/issue/preeminent-hospitals-penalized-over-rates-patients-injuries Medicare reimbursement restrictions are a controversial stimulus to motivate hospital acquired con…

3117. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41277/psn-pdf
      November 28, 2012 - AHRQ 2012 Annual Conference. November 28, 2012 Agency for Healthcare Research and Quality. September 9–12, 2012; Bethesda North Marriott Hotel & Conference Center, Bethesda, MD. https://psnet.ahrq.gov/issue/ahrq-2012-annual-conference The Agency for Healthcare Research and Quality's 2012 conference, "Moving Ahead:…

3118. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41705/psn-pdf
      September 26, 2012 - Teamwork errors in trauma resuscitation. September 26, 2012 Sarcevic A, Marsic I, Burd RS. Teamwork Errors in Trauma Resuscitation. ACM Trans Comput Hum Interact. 2012;19(2):13:1-13:30. doi:10.1145/2240156.2240161. https://psnet.ahrq.gov/issue/teamwork-errors-trauma-resuscitation This study examines the nature of …

3119. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38478/psn-pdf
      March 11, 2009 - Medication administration process assessment: applying lessons learned from commercial aviation. March 11, 2009 Donahue M, Brown JP, Fitzpatrick JJ. Medication administration process assessment: applying lessons learned from commercial aviation. J Nurs Admin. 2009;39(2):77-83. doi:10.1097/NNA.0b013e318195a5e6. htt…

3120. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74142/psn-pdf
      January 02, 2024 - Robert L. Wears Patient Safety Leadership Award. November 1, 2023 Regional Center at Jacksonville University, University of Florida College of Medicine – Jacksonville, FL. https://psnet.ahrq.gov/issue/robert-l-wears-patient-safety-leadership-award Inspired by the research and leadership of Dr. Robert Wears, this aw…