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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50604/psn-pdf
    October 30, 2019 - Speaking up about patient safety requires an observant questioner and a high index of suspicion. October 30, 2019 ISMP Medication Safety Alert! Acute Care Edition. October 10, 2019;24. https://psnet.ahrq.gov/issue/speaking-about-patient-safety-requires-observant-questioner-and-high-index- suspicion The bundling o…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846765/psn-pdf
    March 29, 2023 - Addressing Medical Gaslighting to Improve Maternal Health—Together. March 29, 2023 Oregon Patient Safety Commission: 2023. https://psnet.ahrq.gov/issue/addressing-medical-gaslighting-improve-maternal-health-together Gaslighting has been identified as a contributor to maternal mortality and morbidity. This toolkit …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42910/psn-pdf
    July 28, 2014 - Feeling safe during an inpatient hospitalization: a concept analysis. July 28, 2014 Mollon D. Feeling safe during an inpatient hospitalization: a concept analysis. J Adv Nurs. 2014;70(8):1727-37. doi:10.1111/jan.12348. https://psnet.ahrq.gov/issue/feeling-safe-during-inpatient-hospitalization-concept-analysis Thi…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36446/psn-pdf
    March 28, 2011 - Healthcare provider complaints to the emergency department: a preliminary report on a new quality improvement instrument. March 28, 2011 Griffey RT, Bohan JS. Healthcare provider complaints to the emergency department: a preliminary report on a new quality improvement instrument. Qual Saf Health Care. 2006;15(5):3…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38532/psn-pdf
    January 13, 2017 - Triggers and Targeted Injury Detection Systems (TIDS) Expert Panel Meeting: Conference Summary Report. January 13, 2017 Rockville, MD: Agency for Healthcare Research and Quality; February 2009. AHRQ Publication No. 090003. https://psnet.ahrq.gov/issue/triggers-and-targeted-injury-detection-systems-tids-expert-pane…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43185/psn-pdf
    May 14, 2014 - Preventing health care–associated harm in children. May 14, 2014 Walsh KE, Bundy DG, Landrigan CP. Preventing health care-associated harm in children. JAMA. 2014;311(17):1731-2. doi:10.1001/jama.2014.2038. https://psnet.ahrq.gov/issue/preventing-health-care-associated-harm-children This commentary describes why de…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41419/psn-pdf
    September 26, 2012 - Ten challenges in improving quality in healthcare: lessons from the Health Foundation's programme evaluations and relevant literature. September 26, 2012 Dixon-Woods M, McNicol S, Martin G. Ten challenges in improving quality in healthcare: lessons from the Health Foundation's programme evaluations and relevant li…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43603/psn-pdf
    October 15, 2014 - Coaching to improve the quality of communication during briefings and debriefings. October 15, 2014 Kleiner C, Link T, Maynard T, et al. Coaching to improve the quality of communication during briefings and debriefings. AORN J. 2014;100(4):358-68. doi:10.1016/j.aorn.2014.03.012. https://psnet.ahrq.gov/issue/coachi…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36450/psn-pdf
    December 22, 2010 - Unintended Exposure of Patient Lisa Norris During Radiotherapy Treatment at the Beatson Oncology Centre, Glasgow in January 2006. December 22, 2010 Johnson AM. Edinburgh, Scotland: Health Department; 2006. ISBN 0755962974. https://psnet.ahrq.gov/issue/unintended-exposure-patient-lisa-norris-during-radiotherapy-tre…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42951/psn-pdf
    September 16, 2014 - Novel approach to cardiac alarm management on telemetry units. September 16, 2014 Whalen DA, Covelle PM, Piepenbrink JC, et al. Novel approach to cardiac alarm management on telemetry units. J Cardiovasc Nurs. 2014;29(5):E13-22. doi:10.1097/JCN.0000000000000114. https://psnet.ahrq.gov/issue/novel-approach-cardiac-…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73860/psn-pdf
    September 22, 2021 - A system safety approach to assessing risks in the sepsis treatment process. September 22, 2021 Kaya GK. A system safety approach to assessing risks in the sepsis treatment process. Appl Ergon. 2021;94:103408. doi:10.1016/j.apergo.2021.103408. https://psnet.ahrq.gov/issue/system-safety-approach-assessing-risks-sep…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41537/psn-pdf
    December 30, 2014 - Deaths due to medical error: jumbo jets or just small propeller planes? December 30, 2014 Shojania KG. Deaths due to medical error: jumbo jets or just small propeller planes? BMJ Qual Saf. 2012;21(9). doi:10.1136/bmjqs-2012-001368. https://psnet.ahrq.gov/issue/deaths-due-medical-error-jumbo-jets-or-just-small-prop…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36912/psn-pdf
    September 01, 2011 - Multi-level strategies to achieve resilience for an organisation operating at capacity: a case study at a trauma centre. September 1, 2011 Miller A, Xiao Y. Multi-level strategies to achieve resilience for an organisation operating at capacity: a case study at a trauma centre. Cognition, Technology & Work. 2006;9(…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40516/psn-pdf
    July 15, 2013 - Characteristics of unsafe undergraduate nursing students in clinical practice: an integrative literature review. July 15, 2013 Killam LA, Luhanga F, Bakker D. Characteristics of unsafe undergraduate nursing students in clinical practice: an integrative literature review. J Nurs Educ. 2011;50(8):437-46. doi:10.3928/…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41603/psn-pdf
    August 22, 2012 - Nurse–pharmacist collaboration on medication reconciliation prevents potential harm. August 22, 2012 Feldman LS, Costa LL, Feroli R, et al. Nurse-pharmacist collaboration on medication reconciliation prevents potential harm. J Hosp Med. 2012;7(5):396-401. doi:10.1002/jhm.1921. https://psnet.ahrq.gov/issue/nurse-ph…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39643/psn-pdf
    December 21, 2014 - A systematic quantitative assessment of risks associated with poor communication in surgical care. December 21, 2014 Nagpal K, Vats A, Ahmed K, et al. A systematic quantitative assessment of risks associated with poor communication in surgical care. Arch Surg. 2010;145(6):582-8. doi:10.1001/archsurg.2010.105. http…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38198/psn-pdf
    May 05, 2018 - ISMP's second QuarterWatch report shows sharp increase in reports of serious adverse drug events. May 5, 2018 ISMP Medication Safety Alert! Acute Care Edition. October 23, 2008;13:1-3. https://psnet.ahrq.gov/issue/ismps-second-quarterwatch-report-shows-sharp-increase-reports-serious- adverse-drug-events This news…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60691/psn-pdf
    July 15, 2020 - A mixed-methods systematic review of interventions to address incivility in nursing. July 15, 2020 Olsen JM, Aschenbrenner A, Merkel R, et al. A mixed-methods systematic review of interventions to address incivility in nursing. J Nurs Educ. 2020;59(6):319-326. doi:10.3928/01484834-20200520-04. https://psnet.ahrq.g…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40292/psn-pdf
    March 16, 2011 - Patterns of unexpected in-hospital deaths: a root cause analysis. March 16, 2011 Lynn LA, Curry P. Patterns of unexpected in-hospital deaths: a root cause analysis. Patient Saf Surg. 2011;5(1):3. doi:10.1186/1754-9493-5-3. https://psnet.ahrq.gov/issue/patterns-unexpected-hospital-deaths-root-cause-analysis This l…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38013/psn-pdf
    March 09, 2009 - Agreement between patient-reported symptoms and their documentation in the medical record. March 9, 2009 Pakhomov S, Jacobsen SJ, Chute CG, et al. Agreement between patient-reported symptoms and their documentation in the medical record. Am J Manag Care. 2008;14(8):530-539. https://psnet.ahrq.gov/issue/agreement-b…
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