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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40690/psn-pdf
    August 17, 2011 - Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. August 17, 2011 Steelman VM, Cullen JJ. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. AORN J. 2011;94(2):132-41. doi:10.1016/j.aorn.2010.09.…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855430/psn-pdf
    November 15, 2023 - Authentic leadership at the Cleveland Clinic: psychological safety in the midst of crisis. November 15, 2023 Porter TH, Peck JA, Bolwell B, et al. Authentic leadership at the Cleveland Clinic: psychological safety in the midst of crisis. BMJ Lead. 2023;7(3):196-202. doi:10.1136/leader-2022-000626. https://psnet.ah…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45423/psn-pdf
    September 27, 2016 - Lost in translation: impact of language barriers on children's healthcare. September 27, 2016 Goenka PK. Lost in translation: impact of language barriers on children's healthcare. Curr Opin Pediatr. 2016;28(5):659-666. doi:10.1097/MOP.0000000000000404. https://psnet.ahrq.gov/issue/lost-translation-impact-language-…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47852/psn-pdf
    May 08, 2019 - Impact of time pressure on dentists' diagnostic performance. May 8, 2019 Plessas A, Nasser M, Hanoch Y, et al. Impact of time pressure on dentists' diagnostic performance. J Dent. 2019;82:38-44. doi:10.1016/j.jdent.2019.01.011. https://psnet.ahrq.gov/issue/impact-time-pressure-dentists-diagnostic-performance This…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837639/psn-pdf
    July 06, 2022 - Evaluation of the culture of safety and quality in pediatric primary care practices. July 6, 2022 Oyegoke S, Gigli KH. Evaluation of the culture of safety and quality in pediatric primary care practices. J Patient Saf. 2022;18(4):e753-e759. doi:10.1097/pts.0000000000000942. https://psnet.ahrq.gov/issue/evaluation-…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48075/psn-pdf
    June 19, 2019 - A mismatch made in America. June 19, 2019 Butcher L. Managed Care. June 2019;28:37-39. https://psnet.ahrq.gov/issue/mismatch-made-america Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient errors. This magazine article reports on the complex nature of addressing …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45826/psn-pdf
    January 18, 2017 - Ensuring staff safety when treating potentially violent patients. January 18, 2017 Roca RP, Charen B, Boronow J. Ensuring Staff Safety When Treating Potentially Violent Patients. JAMA. 2016;316(24):2669-2670. doi:10.1001/jama.2016.18260. https://psnet.ahrq.gov/issue/ensuring-staff-safety-when-treating-potentially-…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41432/psn-pdf
    October 19, 2012 - Adverse events are common on the intensive care unit: results from a structured record review. October 19, 2012 Nilsson L, Pihl A, Tågsjö M, et al. Adverse events are common on the intensive care unit: results from a structured record review. Acta Anaesthesiol Scand. 2012;56(8):959-65. doi:10.1111/j.1399- 6576.201…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37171/psn-pdf
    October 06, 2011 - Disclosing unanticipated outcomes to patients: the art and practice. October 6, 2011 Gallagher TH; Denham CR; Leape LL; Amori G; Levinson W. https://psnet.ahrq.gov/issue/disclosing-unanticipated-outcomes-patients-art-and-practice Although medical errors remain disturbingly common, many patients are never informed …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50428/psn-pdf
    September 04, 2019 - Patient safety incidents caused by poor quality surgical instruments. September 4, 2019 Dominguez ED, Rocos B. Patient Safety Incidents Caused by Poor Quality Surgical Instruments. Cureus. 2019;11(6):e4877. doi:10.7759/cureus.4877. https://psnet.ahrq.gov/issue/patient-safety-incidents-caused-poor-quality-surgical-…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44255/psn-pdf
    November 09, 2015 - Biopsy site selfies—a quality improvement pilot study to assist with correct surgical site identification. November 9, 2015 Nijhawan RI, Lee EH, Nehal KS. Biopsy site selfies--a quality improvement pilot study to assist with correct surgical site identification. Dermatol Surg. 2015;41(4):499-504. doi:10.1097/DSS.00…

  12. Workplace Safety in Health Care | PSNet

    psnet.ahrq.gov/perspective/workplace-safety-health-care
    January 01, 2017 - that produces immediate results, but after people get the rhythm of learning—ideally in real time, by identifying

  13. In Conversation With… Paul H. O'Neill, MPA | PSNet

    psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa
    January 01, 2017 - that produces immediate results, but after people get the rhythm of learning—ideally in real time, by identifying

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837902/psn-pdf
    August 24, 2022 - Development and pilot evaluation of an electronic health record usability and safety self-assessment tool. August 24, 2022 Pruitt Z, Howe JL, Krevat S, et al. Development and pilot evaluation of an electronic health record usability and safety self-assessment tool. JAMIA Open. 2022;5(3):ooac070. doi:10.1093/jamiaop…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47697/psn-pdf
    April 03, 2019 - Engineering a foundation for partnership to improve medication safety during care transitions. April 3, 2019 Xiao Y, Abebe E, Gurses AP. Engineering a Foundation for Partnership to Improve Medication Safety during Care Transitions. J Patient Saf Risk Manag. 2019;24(1):30-36. doi:10.1177/2516043518821497. https://p…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838914/psn-pdf
    October 26, 2022 - Veterans Health Administration response to the COVID-19 crisis: surveillance to action. October 26, 2022 Charles MA, Yackel EE, Mills PD, et al. Veterans Health Administration response to the COVID-19 crisis: surveillance to action. J Patient Saf. 2022;18(7):686-691. doi:10.1097/pts.0000000000000995. https://psnet…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867757/psn-pdf
    March 12, 2025 - Improving medication-related safety for residents in nursing homes: a qualitative study. March 12, 2025 Shieu B, Lee Y-W, Epps F, et al. Improving medication-related safety for residents in nursing homes: a qualitative study. J Gerontol Nurs. 2025;51(3):38-43. doi:10.3928/00989134-20250102-03. https://psnet.ahrq.g…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867633/psn-pdf
    February 26, 2025 - Failure to rescue female patients undergoing high-risk surgery. February 26, 2025 Wagner CM, Joynt Maddox KE, Ailawadi G, et al. Failure to rescue female patients undergoing high-risk surgery. JAMA Surg. 2024;160(1):29-36. doi:10.1001/jamasurg.2024.4574. https://psnet.ahrq.gov/issue/failure-rescue-female-patients-…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74746/psn-pdf
    February 09, 2022 - Medication errors' causes analysis in home care setting: a systematic review. February 9, 2022 Dionisi S, Di Simone E, Liquori G, et al. Medication errors' causes analysis in home care setting: A systematic review. Public Health Nurs. 2022;39(4):876-897. doi:10.1111/phn.13037. https://psnet.ahrq.gov/issue/medicati…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46058/psn-pdf
    October 23, 2018 - Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. October 23, 2018 Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8). doi:10.100…
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