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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43184/psn-pdf
    May 14, 2014 - Often overlooked problems with handoffs: from the intensive care unit to the operating room. May 14, 2014 Evans AS, Yee M-S, Hogue CW. Often overlooked problems with handoffs: from the intensive care unit to the operating room. Anesth Analg. 2014;118(3):687-9. doi:10.1213/ANE.0000000000000075. https://psnet.ahrq.g…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73966/psn-pdf
    October 13, 2021 - Prescribing errors with low-molecular-weight heparins. October 13, 2021 Slikkerveer M, van de Plas A, Driessen JHM, et al. Prescribing errors with low-molecular-weight heparins. J Patient Saf. 2021;17(7):e587-e592. doi:10.1097/pts.0000000000000417. https://psnet.ahrq.gov/issue/prescribing-errors-low-molecular-weigh…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46900/psn-pdf
    August 29, 2018 - Developing agreement on never events in primary care dentistry: an international eDelphi study. August 29, 2018 Ensaldo-Carrasco E, Carson-Stevens A, Cresswell K, et al. Developing agreement on never events in primary care dentistry: an international eDelphi study. Br Dent J. 2018;224(9):733-740. doi:10.1038/sj.bd…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41894/psn-pdf
    January 01, 2016 - Simulator-based crew resource management training for interhospital transfer of critically ill patients by a mobile ICU. January 9, 2013 Droogh JM, Kruger HL, Ligtenberg JJM, et al. Simulator-Based Crew Resource Management Training for Interhospital Transfer of Critically Ill Patients by a Mobile ICU. Jt Comm J Qu…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43997/psn-pdf
    August 02, 2015 - Sentinel events, serious reportable events, and root cause analysis. August 2, 2015 Chen TC, Schein OD, Miller JW. Sentinel events, serious reportable events, and root cause analysis. JAMA Ophthalmol. 2015;133(6):631-632. doi:10.1001/jamaophthalmol.2015.0672. https://psnet.ahrq.gov/issue/sentinel-events-serious-re…

  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/42623/psn-pdf
    October 02, 2013 - Unintended adverse consequences of introducing electronic health records in residential aged care homes. October 2, 2013 Yu P, Zhang Y, Gong Y, et al. Unintended adverse consequences of introducing electronic health records in residential aged care homes. Int J Med Inform. 2013;82(9):772-88. doi:10.1016/j.ijmedinf.…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42967/psn-pdf
    February 26, 2014 - Managing competing demands through task-switching and multitasking: a multi-setting observational study of 200 clinicians over 1000 hours. February 26, 2014 Walter SR, Li L, Dunsmuir WTM, et al. Managing competing demands through task-switching and multitasking: a multi-setting observational study of 200 clinician…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47583/psn-pdf
    December 05, 2018 - Interpersonal and organizational dynamics are key drivers of failure to rescue. December 5, 2018 Smith ME, Wells EE, Friese CR, et al. Interpersonal And Organizational Dynamics Are Key Drivers Of Failure To Rescue. Health Aff (Millwood). 2018;37(11):1870-1876. doi:10.1377/hlthaff.2018.0704. https://psnet.ahrq.gov/…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46380/psn-pdf
    September 06, 2017 - What defines a high-performing health system: a systematic review. September 6, 2017 Ahluwalia SC, Damberg CL, Silverman M, et al. What Defines a High-Performing Health Care Delivery System: A Systematic Review. Jt Comm J Qual Patient Saf. 2017;43(9):450-459. doi:10.1016/j.jcjq.2017.03.010. https://psnet.ahrq.gov…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47872/psn-pdf
    March 27, 2019 - Overview of the Environmental Scan of Primary Care- Based Effort To Reduce Readmissions. March 27, 2019 Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF. https://psnet.ahrq.gov/issue/overview-environmental-scan-primar…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47129/psn-pdf
    September 05, 2018 - Impact of medication reconciliation for improving transitions of care. September 5, 2018 Redmond P, Grimes TC, McDonnell R, et al. Impact of medication reconciliation for improving transitions of care. Cochrane Database Syst Rev. 2018;8(8):CD010791. doi:10.1002/14651858.CD010791.pub2. https://psnet.ahrq.gov/issue/…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44326/psn-pdf
    October 21, 2015 - Safety first! Using a checklist for intrafacility transport of adult intensive care patients. October 21, 2015 Comeau OY, Armendariz-Batiste J, Woodby SA. Safety First! Using a Checklist for Intrafacility Transport of Adult Intensive Care Patients. Crit Care Nurse. 2015;35(5):16-25. doi:10.4037/ccn2015991. https:/…

  14. 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-…

  15. 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…

  16. 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…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60066/psn-pdf
    March 25, 2020 - Some Patients Can't Wait: Improving Timeliness of Emergency Department Care March 25, 2020 Chang R, Barnes DK. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care D…

  18. Hospital board and management practices are strongly related to hospital performance on clinical quality metrics. | PSNet

    psnet.ahrq.gov/issue/hospital-board-and-management-practices-are-strongly-related-hospital-performance-clinical
    October 27, 2021 - Study Classic Hospital board and management practices are strongly related to hospital performance on clinical quality metrics. Citation Text: Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to hospital performanc…

  19. Using harm-based weights for the AHRQ Patient Safety for Selected Indicators composite (PSI-90): does it affect assessment of hospital performance and financial penalties in Veterans Health Administration hospitals? | PSNet

    psnet.ahrq.gov/issue/using-harm-based-weights-ahrq-patient-safety-selected-indicators-composite-psi-90-does-it
    March 15, 2016 - Study Using harm-based weights for the AHRQ Patient Safety for Selected Indicators composite (PSI-90): does it affect assessment of hospital performance and financial penalties in Veterans Health Administration hospitals? Citation Text: Chen Q, Rosen AK, Borzecki A, et al. Using Harm-Bas…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73575/psn-pdf
    August 04, 2021 - Unlocking Solutions in Imaging: Working Together to Learn from Failings in the NHS. August 4, 2021 Manchester, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016.  https://psnet.ahrq.gov/issue/unlocking-solutions-imaging-working-together-learn-failings-nhs Lack of appropriate follow up o…
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