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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40412/psn-pdf
    March 23, 2012 - Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections. March 23, 2012 Jain R, Kralovic SM, Evans ME, et al. Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections. N Engl J Med. 2011;364(15):1419-30. doi:10.1056/NEJMoa1007474. https://p…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46340/psn-pdf
    September 27, 2017 - A systematic review of the effectiveness of interruptive medication prescribing alerts in hospital CPOE systems to change prescriber behavior and improve patient safety. September 27, 2017 Page N, Baysari MT, Westbrook JI. A systematic review of the effectiveness of interruptive medication prescribing alerts in ho…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44471/psn-pdf
    September 27, 2016 - Two sides of the safety coin?: how patient engagement and safety climate jointly affect error occurrence in hospital units. September 27, 2016 Schiffinger M, Latzke M, Steyrer J. Two sides of the safety coin?: How patient engagement and safety climate jointly affect error occurrence in hospital units. Health Care …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45511/psn-pdf
    July 21, 2017 - Can patient involvement improve patient safety? A cluster randomised control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention. July 21, 2017 Lawton R, O'Hara JK, Sheard L, et al. Can patient involvement improve patient safety? A cluster randomised control trial of the Patient R…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46295/psn-pdf
    September 06, 2017 - Pain assessment and management standards for hospitals. September 6, 2017 R3 Report. August 29, 2017;11:1-7. https://psnet.ahrq.gov/issue/pain-assessment-and-management-standards-hospitals Strategies to manage pain safely have been reexamined in light of the opioid epidemic. This report highlights Joint Commissio…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44457/psn-pdf
    September 29, 2017 - Hospitals slow to adopt patient apology policies. September 29, 2017 Rice S. Hospitals slow to adopt patient apology policies. Modern healthcare. 2015;45(33):16, 29-30. https://psnet.ahrq.gov/issue/hospitals-slow-adopt-patient-apology-policies Communication-and-resolution approaches to medical errors have garnered …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43657/psn-pdf
    November 26, 2014 - Strategies for Ensuring the Safe Use of Insulin Pens in the Hospital. November 26, 2014 American Society of Health-System Pharmacists https://psnet.ahrq.gov/issue/strategies-ensuring-safe-use-insulin-pens-hospital Insulin is classified as a high-alert medication due to the potential to cause serious patient harm w…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45223/psn-pdf
    September 27, 2017 - Hospital safety climate and safety behavior: a social exchange perspective. September 27, 2017 Ancarani A, Di Mauro C, Giammanco MD. Hospital safety climate and safety behavior: A social exchange perspective. Health Care Manage Rev. 2017;42(4):341-351. doi:10.1097/HMR.0000000000000118. https://psnet.ahrq.gov/issue…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853076/psn-pdf
    August 30, 2023 - Hospital bosses ignored months of doctors' warnings about Lucy Letby. August 30, 2023 Moritz J, Coffey J, Buchanan M. BBC News. August 19, 2023. https://psnet.ahrq.gov/issue/hospital-bosses-ignored-months-doctors-warnings-about-lucy-letby Whistleblowers can identify the presence of systemic failures, but the organ…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46167/psn-pdf
    June 07, 2017 - Identifying patients with sepsis on the hospital wards. June 7, 2017 Bhattacharjee P, Edelson DP, Churpek MM. Identifying Patients With Sepsis on the Hospital Wards. Chest. 2016;151(4). doi:10.1016/j.chest.2016.06.020. https://psnet.ahrq.gov/issue/identifying-patients-sepsis-hospital-wards Undiagnosed sepsis can l…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39498/psn-pdf
    February 10, 2015 - The effect of health information technology on quality in U.S. hospitals. February 10, 2015 McCullough JS, Casey M, Moscovice I, et al. The effect of health information technology on quality in U.S. hospitals. Health Aff (Millwood). 2010;29(4):647-654. doi:10.1377/hlthaff.2010.0155. https://psnet.ahrq.gov/issue/ef…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44531/psn-pdf
    September 30, 2015 - Never Events for Hospital Care in Canada: Safer Care for Patients. September 30, 2015 Toronto, ON: Health Quality Ontario and the Canadian Patient Safety Institute; September 2015. ISBN: 9781460666180. https://psnet.ahrq.gov/issue/never-events-hospital-care-canada-safer-care-patients The never events list was dev…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39647/psn-pdf
    November 02, 2010 - Validation of hospital administrative dataset for adverse event screening. November 2, 2010 Verelst S, Jacques J, Van den Heede K, et al. Validation of Hospital Administrative Dataset for adverse event screening. Qual Saf Health Care. 2010;19(5):e25. doi:10.1136/qshc.2009.034306. https://psnet.ahrq.gov/issue/valid…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40329/psn-pdf
    August 25, 2011 - Using prospective clinical surveillance to identify adverse events in hospital. August 25, 2011 Forster AJ, Worthington JR, Hawken S, et al. Using prospective clinical surveillance to identify adverse events in hospital. BMJ Qual Saf. 2011;20(9):756-63. doi:10.1136/bmjqs.2010.048694. https://psnet.ahrq.gov/issue/u…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867395/psn-pdf
    December 18, 2024 - AHRQ National Healthcare Safety Dashboard. December 18, 2024 AHRQ National Healthcare Safety Dashboard. National Action Alliance for Patient and Workforce Safety. https://psnet.ahrq.gov/issue/ahrq-national-healthcare-safety-dashboard The AHRQ National Healthcare Safety Dashboard is one approach to tracking progress…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39059/psn-pdf
    October 28, 2009 - Communication and information deficits in patients discharged to rehabilitation facilities: an evaluation of five acute care hospitals. October 28, 2009 Gandara E, Moniz T, Ungar J, et al. Communication and information deficits in patients discharged to rehabilitation facilities: An evaluation of five acute care h…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39090/psn-pdf
    November 11, 2009 - Nurse reports of adverse events during sedation procedures at a pediatric hospital. November 11, 2009 Lightdale JR, Mahoney LB, Fredette ME, et al. Nurse reports of adverse events during sedation procedures at a pediatric hospital. J Perianesth Nurs. 2009;24(5):300-6. doi:10.1016/j.jopan.2009.07.004. https://psnet…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33926/psn-pdf
    March 07, 2005 - The problems of detecting medication errors in hospitals. March 7, 2005 Barker KN, McConnell WE. The Problems of Detecting Medication Errors in Hospitals. Am J Health Syst Pharm. 1962;19(8):360-369. doi:10.1093/ajhp/19.8.360. https://psnet.ahrq.gov/issue/problems-detecting-medication-errors-hospitals Perhaps the f…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42355/psn-pdf
    February 11, 2015 - Advancing Successful Care Transitions to Improve Outcomes. February 11, 2015 Society of Hospital Medicine https://psnet.ahrq.gov/issue/project-boost-mentored-implementation-program This Web site provides resources associated with the Better Outcomes for Older adults through Safe Transitions project, called Projec…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50580/psn-pdf
    October 23, 2019 - Suspicious insulin injections, nearly a dozen deaths: inside an unfolding investigation at a VA hospital in West Virginia. October 23, 2019 Rein L. Washington Post. October 5, 2019. https://psnet.ahrq.gov/issue/suspicious-insulin-injections-nearly-dozen-deaths-inside-unfolding- investigation-va-hospital The Vete…

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