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  1. Black Box Thinking: Why Most People Never Learn From Their Mistakes—But Some Do. | PSNet

    psnet.ahrq.gov/issue/black-box-thinking-why-most-people-never-learn-their-mistakes-some-do
    November 03, 2015 - Book/Report Black Box Thinking: Why Most People Never Learn From Their Mistakes—But Some Do. Citation Text: Black Box Thinking: Why Most People Never Learn From Their Mistakes—But Some Do. Syed M. New York, NY: Portfolio; 2015. ISBN: 9781591848226. Copy Citation Save …

  2. A better safety net for young doctors. | PSNet

    psnet.ahrq.gov/issue/better-safety-net-young-doctors
    January 13, 2016 - Newspaper/Magazine Article A better safety net for young doctors. Citation Text: A better safety net for young doctors. Landro L. Wall Street Journal. August. 8, 2016. Copy Citation Save Save to your library Print Download PDF Share Faceboo…

  3. Gosport War Memorial Hospital. The Report of the Gosport Independent Panel. | PSNet

    psnet.ahrq.gov/issue/gosport-war-memorial-hospital-report-gosport-independent-panel
    July 25, 2018 - Government Resource Gosport War Memorial Hospital. The Report of the Gosport Independent Panel. Citation Text: Gosport War Memorial Hospital. The Report of the Gosport Independent Panel. Gosport Independent Panel. London, England: Crown Copyright; 2018. ISBN: 9781528604062. Copy Citati…

  4. Variation in Patient Safety Outcomes and the Importance of Being Informed. | PSNet

    psnet.ahrq.gov/issue/variation-patient-safety-outcomes-and-importance-being-informed
    July 02, 2014 - Book/Report Variation in Patient Safety Outcomes and the Importance of Being Informed. Citation Text: Variation in Patient Safety Outcomes and the Importance of Being Informed. Golden, CO: Healthgrades; 2013.    Copy Citation Save Save to your librar…

  5. Patient Safety Indicators | PSNet

    psnet.ahrq.gov/primer/patient-safety-indicators
    June 15, 2024 - Program (PSI 90 only) Hospital Inpatient Quality Reporting (IQR) Program The Leapfrog Hospital Safety Grade … Hospital Survey , and information from other supplemental data sources to produce a single letter grade

  6. Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports. | PSNet

    psnet.ahrq.gov/issue/retained-swabs-following-invasive-procedures-themes-identified-review-nhs-serious-incident
    February 21, 2024 - Book/Report Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports. Citation Text: Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports. Dorset, UK: Health Services Safety Inve…

  7. Chest Tube Complications | PSNet

    psnet.ahrq.gov/web-mm/chest-tube-complications
    September 27, 2023 - The British Thoracic Society ( 7 ) recommends against clamping chest tubes before removal (Grade B evidence … few hours of clamping followed by chest radiography when there is doubt about the safety of removal (Grade

  8. Factors influencing patient safety during postoperative handover. | PSNet

    psnet.ahrq.gov/issue/factors-influencing-patient-safety-during-postoperative-handover
    March 03, 2021 - Review Factors influencing patient safety during postoperative handover. Citation Text: Factors influencing patient safety during postoperative handover. Rose M, Newman SD. AANA J. 2016;84:329-338. Copy Citation Save Save to your library Print Download P…

  9. Do Black and White Patients Experience Similar Rates of Adverse Safety Events at the Same Hospital? | PSNet

    psnet.ahrq.gov/issue/do-black-and-white-patients-experience-similar-rates-adverse-safety-events-same-hospital
    April 07, 2021 - Book/Report Do Black and White Patients Experience Similar Rates of Adverse Safety Events at the Same Hospital? Citation Text: Do Black and White Patients Experience Similar Rates of Adverse Safety Events at the Same Hospital? Gangopadhyaya A. Washington DC; Urban Institute: July 2021. …

  10. More hospitals move to confront medical errors head on. | PSNet

    psnet.ahrq.gov/issue/more-hospitals-move-confront-medical-errors-head
    June 21, 2023 - Audiovisual More hospitals move to confront medical errors head on. Citation Text: More hospitals move to confront medical errors head on. Gorenstein D. Tradeoffs. November 16, 2023. Copy Citation Save Save to your library Print Download PDF Shar…

  11. Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals. | PSNet

    psnet.ahrq.gov/issue/recognizing-excellence-diagnosis-recommended-practices-hospitals
    June 21, 2023 - Book/Report Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals. Citation Text: Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals. Washington, DC: Leapfrog Group; July 2024. Copy Citation Save Save to your library …

  12. Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. | PSNet

    psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings
    June 09, 2021 - Book/Report Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. Citation Text: Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. Farnborough, UK: Healthcare Safety Investigation Branch; June 2021. Copy Citation …

  13. 2022 John M. Eisenberg Patient Safety and Quality Awards. | PSNet

    psnet.ahrq.gov/issue/2022-john-m-eisenberg-patient-safety-and-quality-awards
    August 02, 2023 - Special or Theme Issue 2022 John M. Eisenberg Patient Safety and Quality Awards. Citation Text: 2022 John M. Eisenberg Patient Safety and Quality Awards. Jt Comm J Qual Patient Saf. 2023;49(9):435-450. Copy Citation Save Save to your library Print Down…

  14. Preventing retained surgical items. | PSNet

    psnet.ahrq.gov/issue/preventing-retained-surgical-items
    December 07, 2022 - Commentary Preventing retained surgical items. Citation Text: Weston M, Chiodo C. Preventing retained surgical items. AORN J. 2022;115(6):569-575. doi:10.1002/aorn.13697. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…

  15. Guidelines in Practice: prevention of unintentionally retained surgical items. | PSNet

    psnet.ahrq.gov/issue/guidelines-practice-prevention-unintentionally-retained-surgical-items
    August 03, 2022 - Commentary Guidelines in Practice: prevention of unintentionally retained surgical items. Citation Text: Cochran K. Guidelines in Practice: prevention of unintentionally retained surgical items. AORN J. 2022;116(5):427-440. doi:10.1002/aorn.13804. Copy Citation Format: DOI …

  16. Heart Failure: The Decline of a Historic Transplant Program. | PSNet

    psnet.ahrq.gov/issue/heart-failure-decline-historic-transplant-program
    July 22, 2020 - Special or Theme Issue Heart Failure: The Decline of a Historic Transplant Program. Citation Text: Heart Failure: The Decline of a Historic Transplant Program. Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica. May 2018-May 2019. Copy Citation Save Save t…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49688/psn-pdf
    August 21, 2013 - precautions" by ensuring that all health information and discharge materials are written at or below a 6th grade … Communication with patients should be at or below a 6th grade reading level and the complexity and quantity

  18. The role of the patient in patient safety: what can we learn from healthcare's history? | PSNet

    psnet.ahrq.gov/issue/role-patient-patient-safety-what-can-we-learn-healthcares-history
    June 12, 2024 - Commentary The role of the patient in patient safety: what can we learn from healthcare's history? Citation Text: Leistikow I, Huisman F. The role of the patient in patient safety: What can we learn from healthcare's history? J Patient Saf Risk Manag. 2018;23(4):139-141. doi:10.1177/2516…

  19. The role of physician specialty board certification status in the quality movement. | PSNet

    psnet.ahrq.gov/issue/role-physician-specialty-board-certification-status-quality-movement
    October 01, 2007 - Review The role of physician specialty board certification status in the quality movement. Citation Text: Brennan TA, Horwitz RI, Duffy FD, et al. The Role of Physician Specialty Board Certification Status in the Quality Movement. JAMA. 2004;292(9). doi:10.1001/jama.292.9.1038. Copy …

  20. National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare. | PSNet

    psnet.ahrq.gov/issue/national-priorities-and-goals-aligning-our-efforts-transform-americas-healthcare
    March 23, 2012 - Book/Report National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare. Citation Text: National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare. National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 19…
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