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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42236/psn-pdf
    May 01, 2013 - Nursing student medication errors: a case study using root cause analysis. May 1, 2013 Dolansky MA, Druschel K, Helba M, et al. Nursing student medication errors: a case study using root cause analysis. J Prof Nurs. 2013;29(2):102-8. doi:10.1016/j.profnurs.2012.12.010. https://psnet.ahrq.gov/issue/nursing-student-…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72685/psn-pdf
    January 27, 2021 - Human Factors and Ergonomics in Healthcare. January 27, 2021 Carayon P, Hignett S, Albolino S eds. Int J Qual Health Care. 2021;33(Supp1):1-71.    https://psnet.ahrq.gov/issue/human-factors-and-ergonomics-healthcare Human factors approaches have been identified as one of the primary vehicles to create las…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43011/psn-pdf
    May 20, 2014 - Early warnings, weak signals and learning from healthcare disasters. May 20, 2014 Macrae C. Early warnings, weak signals and learning from healthcare disasters. BMJ Qual Saf. 2014;23(6):440-5. doi:10.1136/bmjqs-2013-002685. https://psnet.ahrq.gov/issue/early-warnings-weak-signals-and-learning-healthcare-disasters …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40198/psn-pdf
    February 09, 2011 - Measures and measurement of high-performance work systems in health care settings: propositions for improvement. February 9, 2011 Etchegaray J, St John C, Thomas EJ. Measures and measurement of high-performance work systems in health care settings: Propositions for improvement. Health Care Manage Rev. 2011;36(1):3…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849338/psn-pdf
    May 24, 2023 - The impact of language barriers on patient care: a pharmacy perspective. May 24, 2023 Patel J. PM Healthcare Journal. Spring 2023(4):5-18. https://psnet.ahrq.gov/issue/impact-language-barriers-patient-care-pharmacy-perspective Language discordance is known to degrade medication safety. The article discusses an exa…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48148/psn-pdf
    August 14, 2019 - Global Patient Safety: Law, Policy and Practice. August 14, 2019 Tingle J, O'Neill C, Shimwell M. New York, NY: Routledge; 2019. ISBN: 9781138052789. https://psnet.ahrq.gov/issue/global-patient-safety-law-policy-and-practice Improving patient safety is a global goal. This book covers error reduction methods used in…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74145/psn-pdf
    January 01, 2022 - Diagnostic Excellence in the ICU: Thinking Critically and Masterfully. December 1, 2021 Bergl PA, Nanchal RS, eds. Crit Care Clin. 2022;38(1):1-158. https://psnet.ahrq.gov/issue/diagnostic-excellence-icu-thinking-critically-and-masterfully Critical care diagnosis is complicated by factors such as stress, patient a…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72688/psn-pdf
    October 06, 2022 - Request for proposals for clinical quality measures to improve diagnosis. October 6, 2022 Palo Alto CA; Gordon and Betty Moore Foundation: February 22, 2022.  https://psnet.ahrq.gov/issue/request-proposals-clinical-quality-measures-improve-diagnosis A lack of consensus on measures for the effectiveness and ac…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44487/psn-pdf
    September 23, 2015 - Patient safety and quality improvement: terminology. September 23, 2015 Pereira-Argenziano L, Levy FH. Patient Safety and Quality Improvement: Terminology. Pediatr Rev. 2015;36(9):403-11; quiz 412-3. doi:10.1542/pir.36-9-403. https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-terminology To Err Is…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42173/psn-pdf
    April 24, 2013 - Hand hygiene and healthcare system change within multi- modal promotion: a narrative review. April 24, 2013 Allegranzi B, Sax H, Pittet D. Hand hygiene and healthcare system change within multi-modal promotion: a narrative review. J Hosp Infect. 2013;83 Suppl 1:S3-10. doi:10.1016/S0195-6701(13)60003-1. https://psn…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46800/psn-pdf
    May 16, 2018 - Ireland investigates cervical cancer screening scandal. May 16, 2018 O'Loughlin E. New York Times. April 30, 2018. https://psnet.ahrq.gov/issue/ireland-investigates-cervical-cancer-screening-scandal Large-scale adverse events should lead to system examination and improvement. This newspaper article reports on misr…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74045/psn-pdf
    November 03, 2021 - ‘They treat me like I’m old and stupid’: seniors decry health providers’ age bias. November 3, 2021 Graham J. Kaiser Health News. October 20, 2021. https://psnet.ahrq.gov/issue/they-treat-me-im-old-and-stupid-seniors-decry-health-providers-age-bias Implicit biases permeate decision making and can impede safe and e…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843322/psn-pdf
    February 01, 2023 - A deadly epidural, delivered by a doctor with a history of mistakes. February 1, 2023 Goldstein J. New York Times. January 23, 2023. https://psnet.ahrq.gov/issue/deadly-epidural-delivered-doctor-history-mistakes Active errors are evident when they occur, yet systemic weaknesses, if not addressed, allow them to rep…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838258/psn-pdf
    October 05, 2022 - Solutions from Professional Regulation and Beyond. October 5, 2022 Safer Care for All. London, England:  Professional Standards Authority for Health and Social Care; 2022. https://psnet.ahrq.gov/issue/solutions-professional-regulation-and-beyond Dedicated leadership is an important component to examine and ad…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867019/psn-pdf
    October 23, 2024 - Reports on Hospital and ASC Performance. October 23, 2024 Reports On Hospital And Asc Performance. Washington DC: The Leapfrog Group; September 2024. https://psnet.ahrq.gov/issue/reports-hospital-and-asc-performance Data collection and transparency are known to motivate change and drive improvement efforts. This se…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35181/psn-pdf
    June 23, 2009 - Communication during trauma resuscitation: do we know what is happening? June 23, 2009 Bergs EAG, Rutten FLPA, Tadros T, et al. Communication during trauma resuscitation: do we know what is happening? Injury. 2005;36(8):905-11. https://psnet.ahrq.gov/issue/communication-during-trauma-resuscitation-do-we-know-what-…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844778/psn-pdf
    September 18, 2019 - Assessing clinical reasoning: targeting the higher levels of the pyramid. September 18, 2019 Thampy H, Willert E, Ramani S. Assessing Clinical Reasoning: Targeting the Higher Levels of the Pyramid. J Gen Intern Med. 2019;34(8):1631-1636. doi:10.1007/s11606-019-04953-4. https://psnet.ahrq.gov/issue/assessing-clinic…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/839328/psn-pdf
    November 02, 2022 - Quality and Safety. November 2, 2022 Iyer R, Walker A, eds. Paediatr Anaesth. 2022;32(11):1176-1272. https://psnet.ahrq.gov/issue/quality-and-safety-1 Progress made in the adoption of infrastructure, Safety I, and Safety II concepts in high- and middle- to lower-income countries around the world support safe pedia…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73327/psn-pdf
    January 25, 2022 - ISMP Medication Safety Self Assessment® for Perioperative Settings. January 25, 2022 Institute for Safe Medication Practices https://psnet.ahrq.gov/issue/ismp-medication-safety-self-assessmentr-perioperative-settings The perioperative setting is a high-risk area for medication errors, should they occur. This asses…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41722/psn-pdf
    October 17, 2012 - Remaking surgical socialization: work hour restrictions, rites of passage, and occupational identity. October 17, 2012 Veazey Brooks J, Bosk CL. Remaking surgical socialization: Work hour restrictions, rites of passage, and occupational identity. Soc Sci Med. 2012;75(9). doi:10.1016/j.socscimed.2012.07.007. https:…
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