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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36021/psn-pdf
    September 24, 2016 - Operational failures and interruptions in hospital nursing. September 24, 2016 Tucker AL, Spear SJ. Operational failures and interruptions in hospital nursing. Health Serv Res. 2006;41(3 Pt 1):643-662. https://psnet.ahrq.gov/issue/operational-failures-and-interruptions-hospital-nursing This study discovered that n…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44066/psn-pdf
    September 21, 2016 - Raising an alarm, doctors fight to yank hospital ICUs into the modern era. September 21, 2016 McFarling UL. STAT. September 7, 2016. https://psnet.ahrq.gov/issue/raising-alarm-doctors-fight-yank-hospital-icus-modern-era Intensive care units (ICUs) are complex environments that harbor various challenges to safe car…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74722/psn-pdf
    February 02, 2022 - Preventing and mitigating radiology system failures: a guide to disaster planning. February 2, 2022 Gibney BT, Roberts JM, D'Ortenzio RM, et al. Preventing and mitigating radiology system failures: a guide to disaster planning. RadioGraphics. 2021;41(7):2111-2126. doi:10.1148/rg.2021210083. https://psnet.ahrq.gov/…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37612/psn-pdf
    February 15, 2011 - Can we use incident reports to detect hospital adverse events? February 15, 2011 Blais R; Bruno D; Bartlett G; Tamblyn R. https://psnet.ahrq.gov/issue/can-we-use-incident-reports-detect-hospital-adverse-events Incident reporting systems are ubiquitous, despite a lack of evidence supporting their utility in identif…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33904/psn-pdf
    January 25, 2016 - Healthcare Cost and Utilization Project (HCUP). January 25, 2016 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/healthcare-cost-and-utilization-project-hcup The Healthcare Cost and Utilization Project (HCUP) is a family of databases and related software tools and products developed throug…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43639/psn-pdf
    October 29, 2014 - Ebola case raises concern about everyday hospital safety. October 29, 2014 Rodricks D. Baltimore Sun. October 14, 2014. https://psnet.ahrq.gov/issue/ebola-case-raises-concern-about-everyday-hospital-safety Although significant progress has been made in improving patient safety over the past decade, many medical e…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867754/psn-pdf
    March 12, 2025 - Decision fatigue in hospital settings: a scoping review. March 12, 2025 Perry K, Jones S, Stumpff JC, et al. Decision fatigue in hospital settings: a scoping review. J Hosp Med. 2024;Epub Nov 11. doi:10.1002/jhm.13550. https://psnet.ahrq.gov/issue/decision-fatigue-hospital-settings-scoping-review Production pressu…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73077/psn-pdf
    March 24, 2021 - Well-Being Playbook 2.0. A COVID-19 Resource for Hospital and Health System Leaders. March 24, 2021 AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021.  https://psnet.ahrq.gov/issue/well-being-playbook-20-covid-19-resource-hospital-and-health-system-leaders Human factors enginee…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41715/psn-pdf
    October 03, 2017 - Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care. October 3, 2017 Makary M. New York, NY: Bloomsbury Press; 2012. ISBN: 9781608198368. https://psnet.ahrq.gov/issue/unaccountable-what-hospitals-wont-tell-you-and-how-transparency-can- revolutionize-health-care This boo…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42914/psn-pdf
    June 18, 2014 - 2013 John M. Eisenberg Patient Safety and Quality Award Recipients Announced. June 18, 2014 Joint Commission. January 27, 2014. https://psnet.ahrq.gov/issue/2013-john-m-eisenberg-patient-safety-and-quality-award-recipients-announced The Eisenberg Award honors individuals and organizations who have made vital accom…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33671/psn-pdf
    July 01, 2008 - The Soil, Not the Seed: The Real Problem with Root Cause Analysis July 1, 2008 Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis Perspective Throughout most of his life, …
  12. psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
    August 01, 2007 - The PeaceHealth Governance Journey in Support of Quality and Safety John L. Haughom, MD | August 1, 2007  Also Read a Conversation View more articles from the same authors. Citation Text: Haughom JL. The PeaceHealth Governance Journey in Support of Quality and …
  13. psnet.ahrq.gov/issue/evaluation-association-between-nursing-home-survey-patient-safety-culture-nhsops-measures-and
    April 05, 2017 - Study Evaluation of the association between Nursing Home Survey on Patient Safety culture (NHSOPS) measures and catheter-associated urinary tract infections: results of a national collaborative. Citation Text: Smith SN, Greene MT, Mody L, et al. Evaluation of the association between Nurs…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853072/psn-pdf
    September 01, 2014 - Compendium of Strategies to Prevent HAIs in Acute Care Hospitals 2014. September 1, 2014 Infect Control Hosp Epidemiol. 2014;35(Suppl 2):s1-s178;35:460-463;797-801. https://psnet.ahrq.gov/issue/compendium-strategies-prevent-hais-acute-care-hospitals-2014 Preventing healthcare-acquired infections (HAIs) remains a p…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44172/psn-pdf
    September 28, 2016 - Preventing high-alert medication errors in hospital patients. September 28, 2016 Anderson P, Townsend T. Am Nurse Today. May 2015;10:18-23. https://psnet.ahrq.gov/issue/preventing-high-alert-medication-errors-hospital-patients High-alert medications have the potential to cause serious patient harm. This article fo…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34811/psn-pdf
    March 28, 2005 - Medication error prevention by clinical pharmacists in two children's hospitals. March 28, 2005 Folli HL; Poole RL; Benitz WE; Russo JC https://psnet.ahrq.gov/issue/medication-error-prevention-clinical-pharmacists-two-childrens-hospitals This prospective study recorded the rate and potential for harm caused by err…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50744/psn-pdf
    December 18, 2019 - EMS crews brought patients to the hospital with misplaced breathing tubes. None of them survived December 18, 2019 Arditi L. Peoples Public Radio. December 3, 2019. https://psnet.ahrq.gov/issue/ems-crews-brought-patients-hospital-misplaced-breathing-tubes-none-them- survived Emergency medical services are often p…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73589/psn-pdf
    August 11, 2021 - Suicide and suicide attempts on hospital grounds and clinic areas. August 11, 2021 Mills PD, Watts BV, Hemphill RR. Suicide and suicide attempts on hospital grounds and clinic areas. J Patient Saf. 2021;17(5):e423-e428. doi:10.1097/pts.0000000000000356. https://psnet.ahrq.gov/issue/suicide-and-suicide-attempts-hos…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852801/psn-pdf
    August 23, 2023 - Nearly all hospital pharmacists say drug shortages are negatively impacting care; a third say impacts are ‘critical.’ August 23, 2023 McPhillips D. CNN. August 10, 2023. https://psnet.ahrq.gov/issue/nearly-all-hospital-pharmacists-say-drug-shortages-are-negatively-impacting- care-third-say Drug shortages present…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838312/psn-pdf
    October 12, 2022 - Causes of adverse events in home mechanical ventilation: a nursing perspective. October 12, 2022 Lipprandt M, Liedtke W, Langanke M, et al. Causes of adverse events in home mechanical ventilation: a nursing perspective. BMC Nurs. 2022;21(1):264. doi:10.1186/s12912-022-01038-2. https://psnet.ahrq.gov/issue/causes-a…

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