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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36795/psn-pdf
    August 26, 2011 - Surgical specimen identification errors: a new measure of quality in surgical care. August 26, 2011 Makary MA, Epstein J, Pronovost P, et al. Surgical specimen identification errors: a new measure of quality in surgical care. Surgery. 2007;141(4):450-5. https://psnet.ahrq.gov/issue/surgical-specimen-identification…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43731/psn-pdf
    December 03, 2014 - Detection of missed injuries in a pediatric trauma center with the addition of acute care pediatric nurse practitioners. December 3, 2014 Resler J, Hackworth J, Mayo E, et al. Detection of missed injuries in a pediatric trauma center with the addition of acute care pediatric nurse practitioners. J Trauma Nurs. 201…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843321/psn-pdf
    February 01, 2023 - Latent and active failures perfectly align to allow a preventable adverse event to reach a patient. February 1, 2023 ISMP Medication Safety Alert! Acute care edition. January 12, 2023;28(1):1-4. https://psnet.ahrq.gov/issue/latent-and-active-failures-perfectly-align-allow-preventable-adverse-event- reach-patient …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44903/psn-pdf
    September 27, 2016 - What would you ideally do if there were no targets? An ethnographic study of the unintended consequences of top-down governance in two clinical settings. September 27, 2016 Allard J, Bleakley A. What would you ideally do if there were no targets? An ethnographic study of the unintended consequences of top-down gov…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45371/psn-pdf
    April 24, 2017 - Patient safety and workplace bullying: an integrative review. April 24, 2017 Houck NM, Colbert AM. Patient Safety and Workplace Bullying: An Integrative Review. J Nurs Care Qual. 2017;32(2):164-171. doi:10.1097/NCQ.0000000000000209. https://psnet.ahrq.gov/issue/patient-safety-and-workplace-bullying-integrative-rev…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47304/psn-pdf
    October 24, 2018 - Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. October 24, 2018 Gupta A, Harrod M, Quinn M, et al. Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. Diagnosis (Berl). 2018;5(3):151-156. doi:10.1515/dx-2018-0014. https://psnet.…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48013/psn-pdf
    May 29, 2019 - Economic outcomes associated with safety interventions by a pharmacist–adjudicated prior authorization consult service. May 29, 2019 Jacob S, Britt RB, Bryan WE, et al. Economic Outcomes Associated with Safety Interventions by a Pharmacist-Adjudicated Prior Authorization Consult Service. J Manag Care Spec Pharm. 2…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47866/psn-pdf
    May 11, 2019 - Effect of a cluster randomised team training intervention on adverse perinatal and maternal outcomes: a stepped wedge study. May 11, 2019 Romijn A, Ravelli A, de Bruijne MC, et al. Effect of a cluster randomised team training intervention on adverse perinatal and maternal outcomes: a stepped wedge study. BJOG. 201…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43794/psn-pdf
    January 14, 2015 - Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. January 14, 2015 Anderson K, Stowasser D, Freeman C, et al. Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48010/psn-pdf
    May 22, 2019 - In-situ interprofessional perinatal drills: the impact of a structured debrief on maximizing training while sensing patient safety threats. May 22, 2019 Greer JA, Haischer-Rollo G, Delorey D, et al. In-situ Interprofessional Perinatal Drills: The Impact of a Structured Debrief on Maximizing Training While Sensing …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36199/psn-pdf
    March 28, 2011 - Time of day effects on the incidence of anesthetic adverse events. March 28, 2011 Wright MC, Phillips-Bute B, Mark JB, et al. Time of day effects on the incidence of anesthetic adverse events. Qual Saf Health Care. 2006;15(4):258-63. https://psnet.ahrq.gov/issue/time-day-effects-incidence-anesthetic-adverse-events…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34807/psn-pdf
    January 01, 2019 - The Quality in Australian Health Care Study. November 18, 2015 Wilson RML, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust. 2019;163(9):458-471. doi:10.5694/j.1326-5377.1995.tb124691.x. https://psnet.ahrq.gov/issue/quality-australian-health-care-study In order to estimate pa…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47012/psn-pdf
    August 01, 2018 - Trigger alerts associated with laboratory abnormalities on identifying potentially preventable adverse drug events in the intensive care unit and general ward. August 1, 2018 Buckley MS, Rasmussen JR, Bikin DS, et al. Trigger alerts associated with laboratory abnormalities on identifying potentially preventable ad…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34803/psn-pdf
    January 05, 2017 - Systematic root cause analysis of adverse drug events in a tertiary referral hospital. January 5, 2017 Rex JH, Turnbull JE, Allen SJ, et al. Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary Referral Hospital. Jt Comm J Qual Improv. 2016;26(10). doi:10.1016/s1070-3241(00)26048-3. https://psnet.ah…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46474/psn-pdf
    November 08, 2017 - Clearing the Error: Using Public Deliberation to Define Patient Roles as Partners in the Diagnostic Process. November 8, 2017 St. Paul, MN: Society to Improve Diagnosis in Medicine, Maxwell School of Citizenship and Public Affairs at Syracuse University, and Jefferson Center; 2017. https://psnet.ahrq.gov/issue/cle…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41561/psn-pdf
    August 01, 2012 - Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems. August 1, 2012 Wright S. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2012. Report No. OEI-06-09-00092. https://psnet.ahrq.gov/issue/few-adverse-events-hospitals-were-reporte…

  17. Network of Patient Safety Databases | Agency for Healthcare Research and Quality

    www.ahrq.gov/data/npsd.html
    March 01, 2025 - Network of Patient Safety Databases Established under the Patient Safety and Quality Improvement Act of 2005, the Network of Patient Safety Databases (NPSD) develops informational tools, including dashboards and chartbooks, to make the data available for meaningful, national learning purposes. It draws upon n…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844759/psn-pdf
    September 18, 2019 - Saving Patient Ryan- can advanced electronic medical records make patient care safer? September 18, 2019 Hydari MZ, Telang R, Marella WM. Manage Sci. 2019;65:2041-2059. https://psnet.ahrq.gov/issue/saving-patient-ryan-can-advanced-electronic-medical-records-make-patient- care-safer This observational study examin…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840488/psn-pdf
    November 30, 2022 - Critical care clinicians' experiences of patient safety during the COVID-19 pandemic. November 30, 2022 Rosen A, Carter D, Applebaum JR, et al. Critical care clinicians' experiences of patient safety during the COVID-19 pandemic. J Patient Saf. 2022;18(8):e1219-e1225. doi:10.1097/pts.0000000000001060. https://psne…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866283/psn-pdf
    July 10, 2024 - Safety and Quality of Parenteral Nutrition: Translating Guidelines into Clinical Practice Considering Different Organizational Settings. July 10, 2024 Am J Health Syst Pharm. 2024;81(supp 3):s73-s136. https://psnet.ahrq.gov/issue/safety-and-quality-parenteral-nutrition-translating-guidelines-clinical-practice- co…
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