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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43022/psn-pdf
    May 29, 2014 - Using simulation to improve root cause analysis of adverse surgical outcomes. May 29, 2014 Slakey DP, Simms ER, Rennie K, et al. Using simulation to improve root cause analysis of adverse surgical outcomes. Int J Qual Health Care. 2014;26(2):144-50. doi:10.1093/intqhc/mzu011. https://psnet.ahrq.gov/issue/using-sim…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42747/psn-pdf
    November 20, 2013 - Drug related problems and pharmacist interventions in a geriatric unit employing electronic prescribing. November 20, 2013 Raimbault-Chupin M, Spiesser-Robelet L, Guir V, et al. Drug related problems and pharmacist interventions in a geriatric unit employing electronic prescribing. Int J Clin Pharm. 2013;35(5):847-…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47809/psn-pdf
    April 03, 2019 - What's in a name? Provider perception of injured John Doe patients. April 3, 2019 Janowak CF, Agarwal SK, Zarzaur BL. What's in a Name? Provider Perception of Injured John Doe Patients. J Surg Res. 2019;238:218-223. doi:10.1016/j.jss.2019.01.027. https://psnet.ahrq.gov/issue/whats-name-provider-perception-injured-…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36917/psn-pdf
    September 01, 2011 - Analysis of deaths related to anesthesia in the period 1996-2004 from closed claims registered by the Danish Patient Insurance Association. September 1, 2011 Hove LD, Steinmetz J, Christoffersen JK, et al. Analysis of deaths related to anesthesia in the period 1996- 2004 from closed claims registered by the Danish…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43449/psn-pdf
    September 03, 2014 - Interventions to reduce medication errors in pediatric intensive care. September 3, 2014 Manias E, Kinney S, Cranswick N, et al. Interventions to reduce medication errors in pediatric intensive care. Ann Pharmacother. 2014;48(10):1313-31. doi:10.1177/1060028014543795. https://psnet.ahrq.gov/issue/interventions-red…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42913/psn-pdf
    January 29, 2014 - What to do with healthcare incident reporting systems. January 29, 2014 Pham JC, Girard T, Pronovost PJ. What to do with healthcare Incident Reporting Systems. J Public Health Res. 2013;2(3). doi:10.4081/jphr.2013.e27. https://psnet.ahrq.gov/issue/what-do-healthcare-incident-reporting-systems Incident reporting sy…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41534/psn-pdf
    July 25, 2012 - Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care. July 25, 2012 Hu Y-Y, Arriaga AF, Roth EM, et al. Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care. Ann Surg. 2012;256(2):203-10. doi:10.1097/SLA.0b013e…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43889/psn-pdf
    February 11, 2015 - Data as a catalyst for change: stories from the frontlines. February 11, 2015 Siegal D, Ruoff G. Data as a catalyst for change: stories from the frontlines. J Healthc Risk Manag. 2015;34(3):18-25. doi:10.1002/jhrm.21161. https://psnet.ahrq.gov/issue/data-catalyst-change-stories-frontlines Analysis of malpractice c…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47551/psn-pdf
    April 08, 2019 - Factors impacting physician use of information charted by others. April 8, 2019 Zozus MN, Penning M, Hammond WE. JAMIA Open. 2019;2:107-114. https://psnet.ahrq.gov/issue/factors-impacting-physician-use-information-charted-others The copy-and-paste phenomenon in clinical documentation can result in perpetuating inc…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43166/psn-pdf
    May 07, 2014 - Are med school grads prepared to practice medicine? May 7, 2014 Angus S, Vu R, Halvorsen AJ, et al. What skills should new internal medicine interns have in july? A national survey of internal medicine residency program directors. Academic medicine : journal of the Association of American Medical Colleges. 2014;89(…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72559/psn-pdf
    December 09, 2020 - The Life and Death of Elizabeth Dixon: A Catalyst for Change. December 9, 2020 Kirkup B. London, England: Crown Copyright; 2020. ISBN 9781528622714. https://psnet.ahrq.gov/issue/life-and-death-elizabeth-dixon-catalyst-change Missed diagnosis of a dangerous condition in utero, treatment errors, lack of respons…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35809/psn-pdf
    February 25, 2015 - Stories from the sharp end: case studies in safety improvement. February 25, 2015 McCarthy D; Blumenthal D. Milbank Q. 2006;84(1):165-200 https://psnet.ahrq.gov/issue/stories-sharp-end-case-studies-safety-improvement This study shares the efforts of six different health care organizations in implementing intervent…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40945/psn-pdf
    November 23, 2011 - The nature and causes of unintended events reported at 10 internal medicine departments. November 23, 2011 Lubberding S, Zwaan L, Timmermans D, et al. The nature and causes of unintended events reported at 10 internal medicine departments. J Patient Saf. 2011;7(4):224-31. doi:10.1097/PTS.0b013e3182388f97. https://…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43014/psn-pdf
    March 12, 2014 - Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem. March 12, 2014 Perez B, Knych SA, Weaver SJ, et al. Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem. J Patient Saf. 2014;10(1):45-51. …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47146/psn-pdf
    June 27, 2018 - Provider perspectives on partnering with parents of hospitalized children to improve safety. June 27, 2018 Rosenberg RE, Williams E, Ramchandani N, et al. Provider Perspectives on Partnering With Parents of Hospitalized Children to Improve Safety. Hosp Pediatr. 2018;8(6):330-337. doi:10.1542/hpeds.2017-0159. https…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847058/psn-pdf
    April 05, 2023 - Care Delivery within Community Mental Health Teams. April 5, 2023 Farnborough, UK: Healthcare Safety Investigation Branch; March 2023. https://psnet.ahrq.gov/issue/care-delivery-within-community-mental-health-teams Patient suicide is a sentinel event. This report examines a suicide incident that identified problems…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41961/psn-pdf
    January 16, 2013 - Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study. January 16, 2013 Williams SD, Phipps D, Ashcroft DM. Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study. Res Social Adm Pharm. 2013;9(1):80-9. doi:10.1…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846168/psn-pdf
    March 15, 2023 - Now is the time to routinely ask patients about safety. March 15, 2023 Gandhi TK. Now Is the Time to Routinely Ask Patients About Safety. Jt Comm J Qual Patient Saf. 2023;49(4):235-236. doi:10.1016/j.jcjq.2023.01.009. https://psnet.ahrq.gov/issue/now-time-routinely-ask-patients-about-safety Safety event reporting …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837702/psn-pdf
    July 20, 2022 - Patient safety informatics: meeting the challenges of emerging digital health. July 20, 2022 McInerney C, Benn J, Dowding D, et al. Patient safety informatics: meeting the challenges of emerging digital health. Stud Health Technol Inform. 2022;290:364-368. doi:10.3233/shti220097. https://psnet.ahrq.gov/issue/patie…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48043/psn-pdf
    October 01, 2023 - Health Services Safety Investigations Body. October 1, 2023 Lytchett House, 13 Freeland Park, Wareham Road, Poole, Dorset, BH16 6FA. https://psnet.ahrq.gov/issue/health-services-safety-investigations-body Independent investigations examine system weaknesses in health care to inform improvement, reduce risk, and pr…
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