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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35101/psn-pdf
    November 04, 2015 - Hospital finances and patient safety outcomes. November 4, 2015 Encinosa W, Bernard DM. Hospital finances and patient safety outcomes. Inquiry. 2005;42(1):60-72. https://psnet.ahrq.gov/issue/hospital-finances-and-patient-safety-outcomes This AHRQ–funded study examined the relationship between hospital profit margin…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837982/psn-pdf
    August 31, 2022 - Patient Safety Incident Response Framework. August 31, 2022 London, England: NHS England; August 2022. https://psnet.ahrq.gov/issue/patient-safety-incident-response-framework Effective response to medical error requires a comprehensive systemic and process-focused incident examination approach to ensure organizati…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40217/psn-pdf
    April 04, 2011 - The objective impact of clinical peer review on hospital quality and safety. April 4, 2011 Edwards MT. The objective impact of clinical peer review on hospital quality and safety. Am J Med Qual. 2011;26(2):110-9. doi:10.1177/1062860610380732. https://psnet.ahrq.gov/issue/objective-impact-clinical-peer-review-hospi…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35022/psn-pdf
    June 22, 2009 - The investigation and analysis of critical incidents and adverse events in healthcare. June 22, 2009 Woloshynowych M, Rogers S, Taylor-Adams S, et al. The investigation and analysis of critical incidents and adverse events in healthcare. Health Technol Assess. 2005;9(19):1-143, iii. https://psnet.ahrq.gov/issue/in…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/859351/psn-pdf
    January 01, 2024 - Changing the patient safety mindset: can safety cases help? December 20, 2023 Sujan M, Habli I. Changing the patient safety mindset: can safety cases help? BMJ Qual Saf. 2024;33(3):145-148. doi:10.1136/bmjqs-2023-016652. https://psnet.ahrq.gov/issue/changing-patient-safety-mindset-can-safety-cases-help Examinatio…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50580/psn-pdf
    October 23, 2019 - Suspicious insulin injections, nearly a dozen deaths: inside an unfolding investigation at a VA hospital in West Virginia. October 23, 2019 Rein L. Washington Post. October 5, 2019. https://psnet.ahrq.gov/issue/suspicious-insulin-injections-nearly-dozen-deaths-inside-unfolding- investigation-va-hospital The Vete…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854264/psn-pdf
    October 04, 2023 - Patient death tied to lack of proper escalation process for barcode scanning failures. October 4, 2023 ISMP Medication Safety Alert! Acute Care edition. 2023;28(19):1-3. https://psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures Lack of experience with distinct process…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37399/psn-pdf
    March 28, 2012 - Factors affecting incident reporting by registered nurses: the relationship of perceptions of the environment for reporting errors, knowledge of the Nursing Practice Act, and demographics on intent to report errors. March 28, 2012 Throckmorton T, Etchegaray J. Factors affecting incident reporting by registered nur…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43211/psn-pdf
    July 16, 2015 - Seeking high reliability in primary care: leadership, tools, and organization. July 16, 2015 Weaver RR. Seeking high reliability in primary care: Leadership, tools, and organization. Health Care Manage Rev. 2015;40(3):183-92. doi:10.1097/HMR.0000000000000022. https://psnet.ahrq.gov/issue/seeking-high-reliability-p…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866201/psn-pdf
    June 26, 2024 - Systemic: How Racism Is Making Us Ill. June 26, 2024 Liverpool L. New York, NY: Astra Publishing House; 2024. ISBN?: ?9781662601675. https://psnet.ahrq.gov/issue/systemic-how-racism-making-us-ill People of color are routinely affected by biased decision making in health care. This book examines the phenomenon of d…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40764/psn-pdf
    December 29, 2014 - Wristbands as aids to reduce misidentification: an ethnographically guided task analysis. December 29, 2014 Smith A, Casey K, Wilson J, et al. Wristbands as aids to reduce misidentification: an ethnographically guided task analysis. Int J Qual Health Care. 2011;23(5):590-9. doi:10.1093/intqhc/mzr045. https://psnet…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73225/psn-pdf
    May 05, 2021 - Black or 'other'? Doctors may be relying on race to make decisions about your health. May 5, 2021 Smith J, Spodak C. CNN. April 25, 2021. https://psnet.ahrq.gov/issue/black-or-other-doctors-may-be-relying-race-make-decisions-about-your-health Race-adjusted decision making tools perpetuate the potential for diagnos…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42405/psn-pdf
    July 10, 2013 - The role of patient involvement in the diagnostic process in internal medicine: a cognitive approach. July 10, 2013 Lucchiari C, Pravettoni G. The role of patient involvement in the diagnostic process in internal medicine: a cognitive approach. Eur J Intern Med. 2013;24(5):411-5. doi:10.1016/j.ejim.2013.01.022. ht…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34799/psn-pdf
    December 23, 2008 - Drug related admissions to a cardiology department; frequency and avoidability. December 23, 2008 Hallas J, Haghfelt T, Gram LF, et al. Drug related admissions to a cardiology department; frequency and avoidability. J Intern Med. 1990;228(4):379-84. https://psnet.ahrq.gov/issue/drug-related-admissions-cardiology-d…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38061/psn-pdf
    November 08, 2008 - Medication errors in pediatric inpatients: prevalence and results of a prevention program. November 8, 2008 Otero P, Leyton A, Mariani G, et al. Medication errors in pediatric inpatients: prevalence and results of a prevention program. Pediatrics. 2008;122(3):e737-43. doi:10.1542/peds.2008-0014. https://psnet.ahrq…

  16. 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…

  17. 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…

  18. 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…

  19. 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…

  20. 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…
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