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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38785/psn-pdf
    September 02, 2009 - An ethnographic study of classifying and accounting for risk at the sharp end of medical wards. September 2, 2009 Dixon-Woods M, Suokas A, Pitchforth E, et al. An ethnographic study of classifying and accounting for risk at the sharp end of medical wards. Soc Sci Med. 2009;69(3):362-9. doi:10.1016/j.socscimed.2009.…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39814/psn-pdf
    January 28, 2015 - Patient safety for global health - developing safe, effective and accessible technologies. January 28, 2015 Qual Saf Health Care. 2010;19(suppl 2):i1-i47. https://psnet.ahrq.gov/issue/patient-safety-global-health-developing-safe-effective-and-accessible- technologies This supplement provides the conclusions of wo…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43864/psn-pdf
    January 28, 2015 - Starter Kit for Alarm Fatigue. January 28, 2015 National Association of Clinical Nurse Specialists; NACNS. https://psnet.ahrq.gov/issue/starter-kit-alarm-fatigue Alarm fatigue has been identified as a serious problem that affects the safety of nursing care. This toolkit provides checklists, resources, and implemen…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43086/psn-pdf
    March 26, 2014 - International Comparisons: A Focus on Quality of Care. March 26, 2014 Ottawa, ON: Canadian Institute for Health Information; January 23, 2014. https://psnet.ahrq.gov/issue/international-comparisons-focus-quality-care This report compared the quality of care in Canada with 34 other countries to identify areas in whi…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43241/psn-pdf
    June 11, 2014 - "It is the left eye, right?" June 11, 2014 Pikkel D, Sharabi-Nov A, Pikkel J. "It is the left eye, right?". Risk Manag Healthc Policy. 2014;7:77-80. doi:10.2147/RMHP.S60728. https://psnet.ahrq.gov/issue/it-left-eye-right In this study, cataract surgeons were asked to identify the correct eye for surgery when given…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41631/psn-pdf
    September 24, 2016 - Interruption handling strategies during paediatric medication administration. September 24, 2016 Colligan L, Bass EJ. Interruption handling strategies during paediatric medication administration. BMJ Qual Saf. 2012;21(11):912-7. doi:10.1136/bmjqs-2011-000292. https://psnet.ahrq.gov/issue/interruption-handling-stra…
  7. 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…
  8. 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…
  9. 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…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36745/psn-pdf
    March 10, 2011 - Reevaluating recovery: perceived violations and preemptive interventions on emergency psychiatry rounds. March 10, 2011 Cohen T, Blatter B, Almeida C, et al. Reevaluating recovery: perceived violations and preemptive interventions on emergency psychiatry rounds. J Am Med Inform Assoc. 2007;14(3):312-9. https://ps…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39500/psn-pdf
    January 03, 2017 - Using in situ simulation to improve in-hospital cardiopulmonary resuscitation. January 3, 2017 Lighthall GK, Poon T, Harrison K. Using in situ simulation to improve in-hospital cardiopulmonary resuscitation. Jt Comm J Qual Patient Saf. 2010;36(5):209-16. https://psnet.ahrq.gov/issue/using-situ-simulation-improve-h…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41013/psn-pdf
    January 01, 2012 - Patient safety in emergency medical services: a systematic review of the literature. December 21, 2011 Bigham BL, Buick JE, Brooks SC, et al. Patient safety in emergency medical services: a systematic review of the literature. Prehosp Emerg Care. 2012;16(1):20-35. doi:10.3109/10903127.2011.621045. https://psnet.ah…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40115/psn-pdf
    January 05, 2011 - Infection control hazards and near misses reported by nursing students. January 5, 2011 Geller NF, Bakken S, Currie LM, et al. Infection control hazards and near misses reported by nursing students. Am J Infect Control. 2010;38(10):811-6. doi:10.1016/j.ajic.2010.06.001. https://psnet.ahrq.gov/issue/infection-contr…
  14. 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…
  15. 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 …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39262/psn-pdf
    March 04, 2011 - Unintended errors with EHR-based result management: a case series. March 4, 2011 Yackel TR, Embi P. Unintended errors with EHR-based result management: a case series. J Am Med Inform Assoc. 2010;17(1):104-7. doi:10.1197/jamia.M3294. https://psnet.ahrq.gov/issue/unintended-errors-ehr-based-result-management-case-se…
  17. psnet.ahrq.gov/glossary/forcing-function
    September 13, 2021 - Forcing Function September 13, 2021 Anonymous (not verified) An aspect of a design that prevents a target action from being performed or allows its performance only if another specific action is performed first. For example, automobiles are now designed so that the driver cannot shift into reverse without first…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40728/psn-pdf
    October 21, 2011 - What prevents incident disclosure, and what can be done to promote it? October 21, 2011 Iedema R, Allen S, Sorensen R, et al. What prevents incident disclosure, and what can be done to promote it? Jt Comm J Qual Patient Saf. 2011;37(9):409-417. https://psnet.ahrq.gov/issue/what-prevents-incident-disclosure-and-wha…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35426/psn-pdf
    September 15, 2009 - Medical malpractice in the People's Republic of China: the 2002 regulation on the handling of medical accidents. September 15, 2009 Harris DM, Wu C-C. Medical malpractice in the People's Republic of China: the 2002 Regulation on the Handling of Medical Accidents. J Law Med Ethics. 2005;33(3):456-77. https://psnet.…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50664/psn-pdf
    November 13, 2019 - Drug Shortages: Root Causes and Potential Solutions. November 13, 2019 Drug Shortage Task Force. Silver Spring, MD: US Food and Drug Administration; 2020. https://psnet.ahrq.gov/issue/drug-shortages-root-causes-and-potential-solutions Drug shortages result from a variety of systemic failures. This report identifies…

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