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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867639/psn-pdf
    February 26, 2025 - Framing diagnostic error: an epidemiological perspective. February 26, 2025 Hunter MK, Singareddy C, Mundt KA. Framing diagnostic error: an epidemiological perspective. Front Public Health. 2024;12:1479750. doi:10.3389/fpubh.2024.1479750. https://psnet.ahrq.gov/issue/framing-diagnostic-error-epidemiological-perspec…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35340/psn-pdf
    July 10, 2008 - Posthospital medication discrepancies: prevalence and contributing factors. July 10, 2008 Coleman EA, Smith JD, Raha D, et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165(16):1842-1847. https://psnet.ahrq.gov/issue/posthospital-medication-discrepancies-prev…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45122/psn-pdf
    October 08, 2016 - Transformational leadership in nursing and medication safety education: a discussion paper. October 8, 2016 Vaismoradi M, Griffiths P, Turunen H, et al. Transformational leadership in nursing and medication safety education: a discussion paper.  J Nurs Manag. 2016;24(7):970-980. doi:10.1111/jonm.12387. https://psn…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48141/psn-pdf
    July 24, 2019 - Evidence Brief: Implementation of High Reliability Organization Principles. July 24, 2019 Veazie S, Peterson K, Bourne D. Washington DC: United States Department of Veterans Affairs; May 2019. https://psnet.ahrq.gov/issue/evidence-brief-implementation-high-reliability-organization-principles This brief evalu…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849339/psn-pdf
    May 24, 2023 - Just a Cup of Tea – an Introduction to the SEIPS Framework. May 24, 2023 Epsom and St Helier University Hospitals. Epsom, UK: National Health Service; March 21, 2023. https://psnet.ahrq.gov/issue/just-cup-tea-introduction-seips-framework The Systems Engineering Initiative for Patient Safety (SEIPS) framework …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854993/psn-pdf
    November 01, 2023 - Building cultures of high reliability: lessons from the high reliability organization paradigm. November 1, 2023 Sutcliffe KM. Building cultures of high reliability: lessons from the high reliability organization paradigm. Anesthesiol Clin. 2023;41(4):707-717. doi:10.1016/j.anclin.2023.03.012. https://psnet.ahrq.g…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47456/psn-pdf
    April 30, 2019 - ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices. April 30, 2019 Horsham, PA: Institute for Safe Medication Practices; 2018. https://psnet.ahrq.gov/issue/ismp-gap-analysis-tool-gat-safe-iv-push-medication-practices Standardized practices have not been uniformly adopted to support safe IV medicati…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42116/psn-pdf
    March 20, 2013 - Rapid response systems as a patient safety strategy: a systematic review. March 20, 2013 Winters BD, Weaver SJ, Pfoh ER, et al. Rapid-response systems as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):417-25. doi:10.7326/0003-4819-158-5-201303051-00009. https://psnet.ahrq.gov/issu…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45618/psn-pdf
    April 24, 2018 - Electronic detection of delayed test result follow-up in patients with hypothyroidism. April 24, 2018 Meyer AND, Murphy DR, Al-Mutairi A, et al. Electronic Detection of Delayed Test Result Follow-Up in Patients with Hypothyroidism. J Gen Intern Med. 2017;32(7). doi:10.1007/s11606-017-3988-z. https://psnet.ahrq.gov…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838025/psn-pdf
    September 07, 2022 - Opportunities to mine EHRs for malpractice risk management and patient safety. September 7, 2022 Adler-Milstein J, Sarkar U, Wachter RM. Opportunities to mine EHRs for malpractice risk management and patient safety. J Patient Saf Risk Manag. 2022;27(4):160-162. doi:10.1177/25160435221097422. https://psnet.ahrq.gov…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837075/psn-pdf
    May 11, 2022 - Lessons Learned from the COVID-19 Pandemic to Improve Diagnosis. Proceedings of a Workshop–in Brief. May 11, 2022 National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022. https://psnet.ahrq.gov/issue/lessons-learned-covid-19-pandemic-improve-diagnosis-proceedin…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850929/psn-pdf
    June 21, 2023 - Requirements for implementing a 'just culture' within healthcare organisations: an integrative review. June 21, 2023 Murray JS, Lee J, Larson S, et al. Requirements for implementing a ‘just culture’ within healthcare organisations: an integrative review. BMJ Open Qual. 2023;12(2):e002237. doi:10.1136/bmjoq-2022- 0…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43750/psn-pdf
    June 21, 2015 - Using a quantitative risk register to promote learning from a patient safety reporting system. June 21, 2015 Mansfield JG, Caplan RA, Campos JS, et al. Using a quantitative risk register to promote learning from a patient safety reporting system. Jt Comm J Qual Patient Saf. 2015;41(2):76-86. https://psnet.ahrq.gov…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41740/psn-pdf
    October 10, 2012 - Effectiveness of a radiofrequency detection system as an adjunct to manual counting protocols for tracking surgical sponges: a prospective trial of 2,285 patients. October 10, 2012 Rupp CC, Kagarise MJ, Nelson SM, et al. Effectiveness of a radiofrequency detection system as an adjunct to manual counting protocols …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850168/psn-pdf
    June 07, 2023 - Home health agency patient experience measures and their relationship to Joint Commission accreditation. June 7, 2023 Longo BA, Schmaltz SP, Barrett SC, et al. Home health agency patient experience measures and their relationship to Joint Commission accreditation. Jt Comm J Qual Patient Saf. 2023;49(6-7):313-319. …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74693/psn-pdf
    January 26, 2022 - Including the reason for use on prescriptions sent to pharmacists: scoping review. January 26, 2022 Mercer K, Carter C, Burns C, et al. Including the reason for use on prescriptions sent to pharmacists: scoping review. JMIR Hum Factors. 2021;8(4):e22325. doi:10.2196/22325. https://psnet.ahrq.gov/issue/including-re…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44637/psn-pdf
    January 22, 2016 - The morbidity and mortality conference in pediatric intensive care as a means for improving patient safety. January 22, 2016 Frey B, Doell C, Klauwer D, et al. The Morbidity and Mortality Conference in Pediatric Intensive Care as a Means for Improving Patient Safety. Pediatr Crit Care Med. 2016;17(1):67-72. doi:10…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46973/psn-pdf
    June 25, 2018 - Balancing innovation and safety when integrating digital tools into health care. June 25, 2018 Auerbach AD, Neinstein A, Khanna R. Balancing Innovation and Safety When Integrating Digital Tools Into Health Care. Ann Intern Med. 2018;168(10):733-734. doi:10.7326/M17-3108. https://psnet.ahrq.gov/issue/balancing-inno…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74006/psn-pdf
    October 27, 2021 - Building patient trust in hospitals: a combination of hospital-related factors and health care clinician behaviors. October 27, 2021 Greene J, Samuel-Jakubos H. Building patient trust in hospitals: a combination of hospital-related factors and health care clinician behaviors. Jt Comm J Qual Patient Saf. 2021;47(12…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47408/psn-pdf
    September 19, 2018 - Ways to Improve Electronic Health Record Safety. September 19, 2018 Philadelphia, PA: Pew Charitable Trusts, American Medical Association, and Medstar Health; 2018. https://psnet.ahrq.gov/issue/ways-improve-electronic-health-record-safety Electronic health records both contribute to and detract from safe care. This…
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