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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861287/psn-pdf
    January 24, 2024 - Organizational resilience as paradox management: a systematic review of the literature. January 24, 2024 Tekletsion BF, Gomes JFDS, Tefera B. Organizational resilience as paradox management: a systematic review of the literature. J Contingencies Crisis Manage. 2024;32(1):e12495. doi:10.1111/1468-5973.12495. https:…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43566/psn-pdf
    December 19, 2014 - Bedside shift reports: what does the evidence say? December 19, 2014 Gregory S, Tan D, Tilrico M, et al. Bedside shift reports: what does the evidence say? J Nurs Adm. 2014;44(10):541-5. doi:10.1097/NNA.0000000000000115. https://psnet.ahrq.gov/issue/bedside-shift-reports-what-does-evidence-say Bedside shift report…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863003/psn-pdf
    February 21, 2024 - Positive Patient Identification. February 21, 2024 Healthcare Safety Investigation Branch (HSIB), Dorset, UK:  Health Services Safety Investigations Body; February 2024. https://psnet.ahrq.gov/issue/positive-patient-identification Patient misidentification can result in medication administration errors, …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43084/psn-pdf
    May 19, 2014 - How can the criminal law support the provision of quality in healthcare? May 19, 2014 Yeung K, Horder J. How can the criminal law support the provision of quality in healthcare? BMJ Qual Saf. 2014;23(6):519-24. doi:10.1136/bmjqs-2013-002688. https://psnet.ahrq.gov/issue/how-can-criminal-law-support-provision-quali…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843323/psn-pdf
    February 01, 2023 - Long-Term Trends of Psychotropic Drug Use in Nursing Homes. February 1, 2023 Grimm CA. Washington DC: Office of the Inspector General; Nov 2022. Report no. OEI-07-20- 00500. https://psnet.ahrq.gov/issue/long-term-trends-psychotropic-drug-use-nursing-homes Misdiagnosis can result in inappropriate medication u…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34637/psn-pdf
    March 02, 2011 - Risk management: extreme honesty may be the best policy. March 2, 2011 Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med. 1999;131(12):963-967. https://psnet.ahrq.gov/issue/risk-management-extreme-honesty-may-be-best-policy This article reviews a humanistic risk management…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853980/psn-pdf
    September 27, 2023 - RFID tags reduce restocking errors of anesthesia medications. September 27, 2023 Banks MA. Specialty Pharmacy Continuum. September 15, 2023. https://psnet.ahrq.gov/issue/rfid-tags-reduce-restocking-errors-anesthesia-medications Radiofrequency identification (RFID) devices are being used to improve processes in the…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39993/psn-pdf
    July 03, 2014 - The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study. July 3, 2014 Krein SL, Damschroder LJ, Kowalski CP, et al. The influence of organizational context on quality improvement and patient safety efforts in infection prev…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837346/psn-pdf
    June 08, 2022 - Decontamination of Surgical Instruments. June 8, 2022 Farnborough, UK; Healthcare Safety Investigation Branch; May 26, 2022. https://psnet.ahrq.gov/issue/decontamination-surgical-instruments Surgical equipment sterilization can be hampered by equipment design, production pressures, process complexity and policy mi…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837908/psn-pdf
    August 24, 2022 - Implication of the COVID-19 Pandemic for Patient Safety: A Rapid Review. August 24, 2022 Integrated Health Services. Geneva, Switzerland: World Health Organization; 2022. ISBN: 9789240055094. https://psnet.ahrq.gov/issue/implication-covid-19-pandemic-patient-safety-rapid-review The COVID-19 pandemic created new r…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855000/psn-pdf
    November 01, 2023 - Perioperative Safety Culture: Principles, Practices, and Pragmatic Approaches. November 1, 2023 McEvoy MD, Abernathy JH, 3rd. Anesthesiol Clin. 2023;41(4):xvii-xix;693-886. https://psnet.ahrq.gov/issue/perioperative-safety-culture-principles-practices-and-pragmatic-approaches Organizational, unit, and team culture…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866530/psn-pdf
    August 14, 2024 - Healthcare Simulation in Nursing Practice. August 14, 2024 Watts PI. Healthcare Simulation in Nursing Practice. Nurs Clin North Am. 2024;59(3):345-510. https://psnet.ahrq.gov/issue/healthcare-simulation-nursing-practice Simulation is an established method to examine nursing process resilience and develop non-techni…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38952/psn-pdf
    September 16, 2009 - Has the pendulum swung too far?; The impact of missed abdominal injuries in the era of nonoperative management. September 16, 2009 Fairfax LM, Christmas B, Deaugustinis M, et al. Has the pendulum swung too far? The impact of missed abdominal injuries in the era of nonoperative management. Am Surg. 2009;75(7):558-6…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47955/psn-pdf
    April 17, 2019 - Will human factors restore faith in the GMC? April 17, 2019 Morgan L, Benson D, McCulloch P. Will human factors restore faith in the GMC? BMJ. 2019;364:l1037. doi:10.1136/bmj.l1037. https://psnet.ahrq.gov/issue/will-human-factors-restore-faith-gmc Investigations into medical mistakes that result in patient harm sh…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42880/psn-pdf
    January 22, 2014 - Applying ethnography to the study of context in healthcare quality and safety. January 22, 2014 Leslie M, Paradis E, Gropper MA, et al. Applying ethnography to the study of context in healthcare quality and safety. BMJ Qual Saf. 2014;23(2):99-105. doi:10.1136/bmjqs-2013-002335. https://psnet.ahrq.gov/issue/applyin…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73354/psn-pdf
    June 02, 2021 - Advancing Maternal Health Equity and Reducing Maternal Mortality Workshop. June 2, 2021 National Academies of Sciences, Engineering, and Medicine. June 7-8, 2021. https://psnet.ahrq.gov/issue/advancing-maternal-health-equity-and-reducing-maternal-mortality-workshop Maternal safety is challenged by clinical, equity…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50594/psn-pdf
    October 30, 2019 - Pharmacist linkage in care transitions: from academic medical center to community. October 30, 2019 Bloodworth LS, Malinowski SS, Lirette ST, et al. Pharmacist linkage in care transitions: from academic medical center to community. J Am Pharm Assoc . 2019;59(6):896-904. doi:10.1016/j.japh.2019.08.011. https://psne…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72667/psn-pdf
    January 20, 2021 - Virtual urgent care quality and safety in the time of Coronavirus. January 20, 2021 Smith SW, Tiu J, Caspers CG, et al. Virtual Urgent Care Quality and Safety in the Time of Coronavirus. Jt Comm J Qual Patient Saf. 2021;47(2):86-98. doi:10.1016/j.jcjq.2020.10.001. https://psnet.ahrq.gov/issue/virtual-urgent-care-q…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866935/psn-pdf
    October 09, 2024 - The Economics of Diagnostic Safety. October 9, 2024 de Bienassis K, Slawomirski L, Kelly D, et al. The Economics Of Diagnostic Safety. Paris, France: OECD Publishing; 2023. https://psnet.ahrq.gov/issue/economics-diagnostic-safety Ineffective diagnostic processes are common, wasteful, and harmful. This analysis exa…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35485/psn-pdf
    May 27, 2011 - Navigating the information technology highway: computer solutions to reduce errors and enhance patient safety. May 27, 2011 Koshy R. Navigating the information technology highway: computer solutions to reduce errors and enhance patient safety. Transfusion (Paris). 2005;45(4 Suppl):189S-205S. https://psnet.ahrq.go…
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