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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73972/psn-pdf
    October 13, 2021 - The less-discussed consequence of healthcare's labor shortage. October 13, 2021 Bean M, Masson G. Becker's Hospital Review. October 4, 2021. https://psnet.ahrq.gov/issue/less-discussed-consequence-healthcares-labor-shortage Staffing shortages can impact the safety of care by enabling burnout, care omission, a…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73319/psn-pdf
    May 26, 2021 - Safety events in children's hospitals during the COVID-19 pandemic. May 26, 2021 Masonbrink AR, Harris M, Hall M, et al. Hosp Pediatr. 2021;11(6):e95-e100. https://psnet.ahrq.gov/issue/safety-events-childrens-hospitals-during-covid-19-pandemic This study analyzed Pediatric Quality Indicators (PDIs) to compare…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44488/psn-pdf
    September 16, 2015 - Environmental Cleaning for the Prevention of Healthcare- Associated Infections (HAIs). September 16, 2015 Leas BF, Sullivan N, Han JH, Pegues DA, Kaczmarek JL, Umscheid CA. Rockville, MD: Agency for Healthcare Research and Quality; August 2015. Technical Brief No. 22. AHRQ Publication No. 15- EHC020-EF. https://p…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44636/psn-pdf
    November 04, 2015 - The most crucial half-hour at a hospital: the shift change. November 4, 2015 Landro L. https://psnet.ahrq.gov/issue/most-crucial-half-hour-hospital-shift-change Information exchange can be challenging when nurses hand off care responsibilities at the end of their shifts. This news article discusses bedside shift r…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/859352/psn-pdf
    December 20, 2023 - More hospitals move to confront medical errors head on. December 20, 2023 Gorenstein D. Tradeoffs. November 16, 2023. https://psnet.ahrq.gov/issue/more-hospitals-move-confront-medical-errors-head Amid governmental guidance to improve safety, front-line perspectives remain an important source for insight to make im…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849130/psn-pdf
    May 17, 2023 - Comparing perspectives on organisational silence: an analysis of the Gosport inquiry. May 17, 2023 Powell M. J Health Org Manag. 2023;37(1):67-83. https://psnet.ahrq.gov/issue/comparing-perspectives-organisational-silence-analysis-gosport-inquiry Individual, team, and organizational willingness to identify and add…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861295/psn-pdf
    January 24, 2024 - Investigators find hospital error caused mother’s death in Brooklyn. January 24, 2024 Goldstein J. New York Times. January 14, 2024. https://psnet.ahrq.gov/issue/investigators-find-hospital-error-caused-mothers-death-brooklyn Maternal safety is challenged in the Unites States and particularly for minorities. This …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47513/psn-pdf
    October 24, 2021 - Measurement and Monitoring of Safety Framework October 24, 2021 Healthcare Excellence Canada. https://psnet.ahrq.gov/issue/measurement-and-monitoring-safety-canada-cpsi-safety-improvement-project Collaboratives are a recognized strategy to support large-scale improvement. This program works to apply a framework fo…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44816/psn-pdf
    June 29, 2016 - Paralyzed by errors, this Xbox designer is taking on hospital safety. June 29, 2016 Aleccia J. https://psnet.ahrq.gov/issue/paralyzed-errors-xbox-designer-taking-hospital-safety Patients who experience harm while receiving medical care can serve as powerful advocates for patient safety. This news article reports …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47112/psn-pdf
    May 09, 2018 - 34 ways to survive your next trip to the hospital. May 9, 2018 Crouch M. Reader's Digest. April 2018. https://psnet.ahrq.gov/issue/34-ways-survive-your-next-trip-hospital Involving patients in their care can help improve safety. This magazine article provides 34 tips from leading patient safety experts to assist p…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37415/psn-pdf
    March 03, 2011 - Six year audit of cardiac arrests and medical emergency team calls in an Australian outer metropolitan teaching hospital. March 3, 2011 Buist M, Harrison J, Abaloz E, et al. Six year audit of cardiac arrests and medical emergency team calls in an Australian outer metropolitan teaching hospital. BMJ. 2007;335(7631)…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37409/psn-pdf
    March 28, 2012 - Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital. March 28, 2012 Sari AB-A, Sheldon T, Cracknell A, et al. Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital. Qual Saf Health Care…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41320/psn-pdf
    May 02, 2012 - Prevalence of error-prone abbreviations used in medication prescribing for hospitalised patients: multi- hospital evaluation. May 2, 2012 Dooley MJ, Wiseman M, Gu G. Prevalence of error-prone abbreviations used in medication prescribing for hospitalised patients: multi-hospital evaluation. Intern Med J. 2012;42(3)…
  14. psnet.ahrq.gov/web-mm/ebola-are-we-ready
    July 01, 2012 - Ebola: Are We Ready? Citation Text: Barsuk JH, Barnard C. Ebola: Are We Ready?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
  15. psnet.ahrq.gov/web-mm/volume-too-low-and-out
    July 01, 2017 - SPOTLIGHT CASE Volume Too Low: In and Out Citation Text: Miller MR. Volume Too Low: In and Out . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…
  16. psnet.ahrq.gov/web-mm/signout-fallout
    November 16, 2022 - SPOTLIGHT CASE Signout Fallout Citation Text: Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…
  17. psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
    August 21, 2015 - SPOTLIGHT CASE Order Interrupted by Text: Multitasking Mishap Citation Text: Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: …
  18. psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
    June 01, 2005 - Diagnostic Failure: The Growing Deficit Citation Text: Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNo…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49830/psn-pdf
    May 01, 2018 - Suicide Risk in the Hospital May 1, 2018 Mills PD. Suicide Risk in the Hospital. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/suicide-risk-hospital The Case A 37-year-old woman with a past medical history of depression, anxiety, and posttraumatic stress disorder presented to the emergency department (ED)…
  20. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
    August 01, 2009 - Spotlight Case July 2008 Spotlight Case Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care * Source and Credits This presentation is based on the August 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME/CEU credit is available Commentary by: …

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