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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46082/psn-pdf
    February 25, 2019 - The opioid crisis: can improving diagnosis help solve the problem? February 25, 2019 Carr S. ImproveDx. April 2017;4:1-4. https://psnet.ahrq.gov/issue/opioid-crisis-can-improving-diagnosis-help-solve-problem The opioid epidemic has been widely discussed, but little research has examined how misdiagnosis can contr…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837703/psn-pdf
    July 20, 2022 - Family safety reporting in hospitalized children with medical complexity. July 20, 2022 Mercer AN, Mauskar S, Baird JD, et al. Family safety reporting in hospitalized children with medical complexity. Pediatrics. 2022;150(2):e2021055098. doi:10.1542/peds.2021-055098. https://psnet.ahrq.gov/issue/family-safety-repo…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46534/psn-pdf
    January 31, 2018 - Safety considerations in learning new procedures: a survey of surgeons. January 31, 2018 Jaffe TA, Hasday SJ, Knol M, et al. Safety considerations in learning new procedures: a survey of surgeons. J Surg Res. 2017;218:361-366. doi:10.1016/j.jss.2017.06.058. https://psnet.ahrq.gov/issue/safety-considerations-learni…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60696/psn-pdf
    July 15, 2020 - Culture as a Cure: Assessments of Patient Safety Culture in OECD Countries. July 15, 2020 de Bienassisi K, Kristensenii S, Burtscheri M, et al for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 119. https://psnet.ahrq.gov/…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42717/psn-pdf
    November 06, 2013 - Current surgical instrument labeling techniques may increase the risk of unintentionally retained foreign objects: a hypothesis. November 6, 2013 Ipaktchi K, Kolnik A, Messina M, et al. Current surgical instrument labeling techniques may increase the risk of unintentionally retained foreign objects: a hypothesis. …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35176/psn-pdf
    June 23, 2009 - Mapping changes in surgical mortality over 9 years by peer review audit. June 23, 2009 Thompson A, Ashraf Z, Burton H, et al. Mapping changes in surgical mortality over 9 years by peer review audit. Br J Surg. 2005;92(11):1449-52. https://psnet.ahrq.gov/issue/mapping-changes-surgical-mortality-over-9-years-peer-re…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50644/psn-pdf
    November 06, 2019 - Hearing: Broken Promises: Assessing VA’s Systems for Protecting Veterans from Clinical Harm. November 6, 2019 US House of Representatives Committee on Veterans Affairs Subcommittee on Oversight and Investigations. 116th Cong, 1st Sess (2019). https://psnet.ahrq.gov/issue/hearing-broken-promises-assessing-vas-syste…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34927/psn-pdf
    June 23, 2009 - Health Care Quality and Disparities: Lessons from the First National Reports. June 23, 2009 Kelley E, Moy E, Dayton E, et al. Med Care. 2005:43(3):I1-I88. https://psnet.ahrq.gov/issue/health-care-quality-and-disparities-lessons-first-national-reports Highlights from AHRQ's two inaugural reports, the 2003 National …

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40545/psn-pdf
    June 22, 2011 - Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes. June 22, 2011 Effken JA, Carley KM, Gephart SM, et al. Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes. Int J Med Inform. 2011;80(7):507-17. doi:10.…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837608/psn-pdf
    September 06, 2023 - Harm Caused by Delays in Transferring Patients to the Right Place of Care. September 6, 2023 Farnborough, UK: Healthcare Safety Investigation Branch; August 2023. https://psnet.ahrq.gov/issue/harm-caused-delays-transferring-patients-right-place-care Handoffs between prehospital emergency medical services (EMS) pro…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47534/psn-pdf
    November 21, 2018 - Resident hesitation in the operating room: does uncertainty equal incompetence? November 21, 2018 Ott M, Schwartz A, Goldszmidt M, et al. Resident hesitation in the operating room: does uncertainty equal incompetence? Med Educ. 2018;52(8):851-860. doi:10.1111/medu.13530. https://psnet.ahrq.gov/issue/resident-hesit…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60897/psn-pdf
    January 01, 2022 - Association between surgeon technical skills and patient outcomes. September 9, 2020 Stulberg JJ, Huang R, Kreutzer L, et al. Association Between Surgeon Technical Skills and Patient Outcomes. JAMA Surg. 2022;157(3):219-220. doi:10.1001/jamasurg.2020.3007. https://psnet.ahrq.gov/issue/association-between-surgeon-t…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43648/psn-pdf
    November 21, 2016 - Patient- and family-centered care: error disclosure and investigation. November 21, 2016 Connor M; Wayman KI; Garcia C; Fischer PR; Consortium for Maximizing Family-Centered Care. https://psnet.ahrq.gov/issue/patient-and-family-centered-care-error-disclosure-and-investigation Patients are increasingly encouraged t…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844556/psn-pdf
    February 15, 2023 - Using Machine Learning to Improve Patient Safety in the Home or Remote Setting for Adults. February 15, 2023 Feske-Kirby K, Whittington J, McGaffigan P. Boston, MA: Institute for Healthcare Improvement; 2022. https://psnet.ahrq.gov/issue/using-machine-learning-improve-patient-safety-home-or-remote-setting-adults T…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47373/psn-pdf
    November 14, 2018 - Blame: what does it look like? November 14, 2018 Duthie EA. Blame: What does it look like? Nurs Manage. 2018;49(11):18-21. doi:10.1097/01.NUMA.0000547256.76967.9e. https://psnet.ahrq.gov/issue/blame-what-does-it-look A just culture balances organizational context with appropriate accountability after an error. Thi…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44525/psn-pdf
    October 21, 2015 - Wound-care teams for preventing and treating pressure ulcers. October 21, 2015 Moore ZEH, Webster J, Samuriwo R. Wound-care teams for preventing and treating pressure ulcers. Cochrane Database Syst Rev. 2015;9:CD011011. doi:10.1002/14651858.CD011011.pub2. https://psnet.ahrq.gov/issue/wound-care-teams-preventing-an…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61003/psn-pdf
    October 07, 2020 - Making Complaints Count: Supporting Complaints Handling in the NHS and UK Government Departments. October 7, 2020 Manchester, UK: The Parliamentary and Health Service Ombudsman; July 15, 2020. ISBN 9781528620666. https://psnet.ahrq.gov/issue/making-complaints-count-supporting-complaints-handling-nhs-and-uk- gover…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849609/psn-pdf
    May 31, 2023 - Impact of diagnostic checklists on the interpretation of normal and abnormal electrocardiograms. May 31, 2023 Staal J, Zegers R, Caljouw-Vos J, et al. Impact of diagnostic checklists on the interpretation of normal and abnormal electrocardiograms. Diagnosis (Berl). 2022;10(2):121-129. doi:10.1515/dx-2022-0092. htt…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47933/psn-pdf
    August 07, 2019 - Just culture: it's more than policy. August 7, 2019 Paradiso L, Sweeney N. Just culture: It's more than policy. Nurs Manage. 2019;50(6):38-45. doi:10.1097/01.NUMA.0000558482.07815.ae. https://psnet.ahrq.gov/issue/just-culture-its-more-policy This survey study examined the relationship between just culture—a cultur…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42404/psn-pdf
    October 08, 2013 - How can we keep patients with dementia safe in our acute hospitals? A review of challenges and solutions. October 8, 2013 George J, Long SJ, Vincent CA. How can we keep patients with dementia safe in our acute hospitals? A review of challenges and solutions. J R Soc Med. 2013;106(9):355-61. doi:10.1177/014107681347…
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