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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/843321/psn-pdfFebruary 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 … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45868/psn-pdfJanuary 31, 2018 - Increasing trainee reporting of adverse events with monthly, trainee-directed review of adverse events. January 31, 2018 Smith A, Hatoun J, Moses J. Increasing Trainee Reporting of Adverse Events With Monthly Trainee- Directed Review of Adverse Events. Acad Pediatr. 2017;17(8):902-906. doi:10.1016/j.acap.2017.01.00… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46129/psn-pdfSeptember 28, 2017 - Missed diagnosis of cardiovascular disease in outpatient general medicine: insights from malpractice claims data. September 28, 2017 Quinn GR, Ranum D, Song E, et al. Missed Diagnosis of Cardiovascular Disease in Outpatient General Medicine: Insights from Malpractice Claims Data. Jt Comm J Qual Patient Saf. 2017;43… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40435/psn-pdfJuly 22, 2011 - How does context affect interventions to improve patient safety? An assessment of evidence from studies of five patient safety practices and proposals for research. July 22, 2011 Ovretveit JC, Shekelle PG, Dy SM, et al. How does context affect interventions to improve patient safety? An assessment of evidence from… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46474/psn-pdfNovember 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… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43992/psn-pdfApril 25, 2016 - Collaborating—or "selling" patients? A conceptual framework for emergency department-to-inpatient handoff negotiations. April 25, 2016 Hilligoss B, Mansfield JA, Patterson ES, et al. Collaborating-or "Selling" Patients? A Conceptual Framework for Emergency Department-to-Inpatient Handoff Negotiations. Jt Comm J Qu… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43667/psn-pdfNovember 12, 2014 - Learning from preventable deaths: exploring case record reviewers' narratives using change analysis. November 12, 2014 Hogan H, Healey F, Neale G, et al. Learning from preventable deaths: exploring case record reviewers' narratives using change analysis. J R Soc Med. 2014;107(9):365-75. doi:10.1177/0141076814532394… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/853610/psn-pdfSeptember 20, 2023 - Ten years later, alarm fatigue is still a safety concern. September 20, 2023 Albanowski K, Burdick KJ, Bonafide CP, et al. Ten years later, alarm fatigue is still a safety concern. AACN Adv Crit Care. 2023;34(3):189-197. doi:10.4037/aacnacc2023662. https://psnet.ahrq.gov/issue/ten-years-later-alarm-fatigue-still-sa… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60803/psn-pdfAugust 12, 2020 - Interprofessional/interdisciplinary teamwork during the early COVID-19 pandemic: experience from a children's hospital within an academic health center. August 12, 2020 Natale JAE, Boehmer J, Blumberg DA, et al. Interprofessional/interdisciplinary teamwork during the early COVID-19 pandemic: experience from a chil… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45845/psn-pdfDecember 19, 2017 - You can't blame the wreck on the train. December 19, 2017 Potts JR. You can't blame the wreck on the train. Am J Surg. 2017;214(5):974-978. doi:10.1016/j.amjsurg.2016.11.046. https://psnet.ahrq.gov/issue/you-cant-blame-wreck-train Insufficient supervision can limit resident education, which may increase risks to p… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60879/psn-pdfSeptember 02, 2020 - Why do hospital prescribers continue antibiotics when it is safe to stop? Results of a choice experiment survey. September 2, 2020 Roope LSJ, Buchanan J, Morrell L, et al. Why do hospital prescribers continue antibiotics when it is safe to stop? Results of a choice experiment survey. BMC Med. 2020;18(1):196. doi:10… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837068/psn-pdfMay 11, 2022 - Barriers and enablers to nurses' use of harm prevention strategies for older patients in hospital: a cross-sectional survey. May 11, 2022 Redley B, Taylor N, Hutchinson A. Barriers and enablers to nurses' use of harm prevention strategies for older patients in hospital: a cross?sectional survey. J Adv Nurs. 2022;7… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45848/psn-pdfNovember 19, 2018 - New Horizons in Patient Safety: Understanding Communication: Case Studies for Physicians. November 19, 2018 Hannawa AF, Wu AW, Juhasz RS, eds. Berlin, Germany: DeGruyter; 2017. ISBN: 9783110455014. https://psnet.ahrq.gov/issue/new-horizons-patient-safety-understanding-communication-case-studies- physicians Poor c… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837983/psn-pdfAugust 31, 2022 - Identifying and Understanding Ways to Address the Impact of Racism on Patient Safety in Health Care Settings. August 31, 2022 Schulson LB, Thomas AD, Tsuei J, et al. Santa Monica, CA: RAND Corporation; 2022 https://psnet.ahrq.gov/issue/identifying-and-understanding-ways-address-impact-racism-patient-safety- … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47279/psn-pdfJuly 23, 2018 - No Place Like Home: Advancing the Safety of Care in the Home. July 23, 2018 Boston, MA: Institute for Healthcare Improvement; 2018. https://psnet.ahrq.gov/issue/no-place-home-advancing-safety-care-home The home care setting harbors unique challenges to patient safety. This report builds on a previous evidence ass… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60724/psn-pdfJuly 29, 2020 - The safety of health care for ethnic minority patients: a systematic review. July 29, 2020 Chauhan A, Walton M, Manias E, et al. The safety of health care for ethnic minority patients: a systematic review. Int J Equity Health. 2020;19(1):118. doi:10.1186/s12939-020-01223-2. https://psnet.ahrq.gov/issue/safety-heal… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44421/psn-pdfOctober 07, 2015 - Classification of antecedents towards safety use of health information technology: a systematic review. October 7, 2015 Salahuddin L, Ismail Z. Classification of antecedents towards safety use of health information technology: A systematic review. Int J Med Inform. 2015;84(11):877-891. doi:10.1016/j.ijmedinf.2015.0… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47912/psn-pdfApril 24, 2019 - A systematic literature review and narrative synthesis on the risks of medical discharge letters for patients' safety. April 24, 2019 Schwarz CM, Hoffmann M, Schwarz P, et al. A systematic literature review and narrative synthesis on the risks of medical discharge letters for patients' safety. BMC Health Serv Res. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/838177/psn-pdfSeptember 28, 2022 - Exploring care left undone in pediatric nursing. September 28, 2022 Bagnasco A, Rossi S, Dasso N, et al. Exploring care left undone in pediatric nursing. J Patient Saf. 2022;18(6):e903-e911. doi:10.1097/pts.0000000000001044. https://psnet.ahrq.gov/issue/exploring-care-left-undone-pediatric-nursing Care left undone… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39199/psn-pdfJanuary 28, 2010 - Nurse decision making in the prearrest period. January 28, 2010 Gazarian PK, Henneman EA, Chandler GE. Nurse decision making in the prearrest period. Clin Nurs Res. 2010;19(1):21-37. doi:10.1177/1054773809353161. https://psnet.ahrq.gov/issue/nurse-decision-making-prearrest-period This qualitative study explored th…
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