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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60303/psn-pdf
    May 06, 2020 - Using safety culture results to guide the merger of four general practices in the UK. May 6, 2020 Lockwood AM, Proulx J, Hill M, et al. Using safety culture results to guide the merger of four general practices in the UK. BMJ Open Qual. 2020;9(1):e000860. doi:10.1136/bmjoq-2019-000860. https://psnet.ahrq.gov/issue…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47365/psn-pdf
    January 01, 2019 - How well do incident reporting systems work on inpatient psychiatric units? December 21, 2018 Reilly CA, Cullen SW, Watts B, et al. How Well Do Incident Reporting Systems Work on Inpatient Psychiatric Units? Jt Comm J Qual Patient Saf. 2019;45(1):63-69. doi:10.1016/j.jcjq.2018.05.002. https://psnet.ahrq.gov/issue/…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47096/psn-pdf
    November 14, 2018 - An analysis of adverse events in the rehabilitation department: using the Veterans Affairs root cause analysis system. November 14, 2018 Hagley GW, Mills PD, Shiner B, et al. An Analysis of Adverse Events in the Rehabilitation Department: Using the Veterans Affairs Root Cause Analysis System. Phys Ther. 2018;98(4)…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852455/psn-pdf
    August 16, 2023 - A quality improvement initiative to improve pediatric discharge medication safety and efficiency. August 16, 2023 Ring LM, Cinotti J, Hom LA, et al. A quality improvement initiative to improve pediatric discharge medication safety and efficiency. Pediatr Qual Saf. 2023;8(4):e671. doi:10.1097/pq9.0000000000000671. …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41954/psn-pdf
    November 26, 2014 - Decoding laboratory test names: a major challenge to appropriate patient care. November 26, 2014 Passiment E, Meisel JL, Fontanesi J, et al. Decoding laboratory test names: a major challenge to appropriate patient care. J Gen Intern Med. 2013;28(3):453-8. doi:10.1007/s11606-012-2253-8. https://psnet.ahrq.gov/issue…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42449/psn-pdf
    July 31, 2013 - The epidemiology of malpractice claims in primary care: a systematic review. July 31, 2013 Wallace E, Lowry J, Smith SM, et al. The epidemiology of malpractice claims in primary care: a systematic review. BMJ Open. 2013;3(7). doi:10.1136/bmjopen-2013-002929. https://psnet.ahrq.gov/issue/epidemiology-malpractice-cl…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851449/psn-pdf
    July 19, 2023 - Perceived disability-based discrimination in health care for children with medical complexity. July 19, 2023 Ames SG, Delaney RK, Houtrow AJ, et al. Perceived disability-based discrimination in health care for children with medical complexity. Pediatrics. 2023;152(1):e2022060975. doi:10.1542/peds.2022-060975. http…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845073/psn-pdf
    February 22, 2023 - Nursing student errors and near misses: three years of data. February 22, 2023 Silvestre JH, Spector ND. Nursing student errors and near misses: three years of data. J Nurs Educ. 2023;62(1):12-19. doi:10.3928/01484834-20221109-05. https://psnet.ahrq.gov/issue/nursing-student-errors-and-near-misses-three-years-data…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41607/psn-pdf
    January 03, 2017 - Using a risk assessment approach to determine which factors influence whether partially bilingual physicians rely on their non-English language skills or call an interpreter. January 3, 2017 Maul L, Regenstein M, Andres E, et al. Using a risk assessment approach to determine which factors influence whether partia…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43137/psn-pdf
    May 28, 2015 - Weaving quality improvement and patient safety skills into all levels of medical training: an annotated bibliography. May 28, 2015 Mochan E, Nash DB. Weaving quality improvement and patient safety skills into all levels of medical training: an annotated bibliography. Am J Med Qual. 2015;30(3):232-47. doi:10.1177/1…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43266/psn-pdf
    June 18, 2014 - That's the way we do things around here! Your actions speak louder than words when it comes to patient safety. June 18, 2014 Grissinger M. That's the Way We Do Things Around Here!: Your Actions Speak Louder Than Words When It Comes To Patient Safety. P T. 2014;39(5):308-44. https://psnet.ahrq.gov/issue/thats-way-w…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843411/psn-pdf
    February 01, 2023 - Sustaining improvement of hospital-wide initiative for patient safety and quality: a systematic scoping review. February 1, 2023 Moon SEJ, Hogden A, Eljiz K. Sustaining improvement of hospital-wide initiative for patient safety and quality: a systematic scoping review. BMJ Open Qual. 2022;11(4):e002057. doi:10.1136…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47494/psn-pdf
    January 01, 2020 - Race differences in reported harmful patient safety events in healthcare system high reliability organizations. January 23, 2019 Thomas AD, Pandit C, Krevat SA. Race Differences in Reported Harmful Patient Safety Events in Healthcare System High Reliability Organizations. J Patient Saf. 2020;16(4):e235-e239. doi:1…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47565/psn-pdf
    April 27, 2019 - Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors. April 27, 2019 Steelman VM, Shaw C, Shine L, et al. Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentinel Events and Contributing Factors. Jt Comm J Qual Patient Saf. 2019;45(4):249…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44120/psn-pdf
    November 06, 2015 - Designing highly reliable adverse-event detection systems to predict subsequent claims. November 6, 2015 Helmchen LA, Burke ME, Wojtusiak J. Designing highly reliable adverse-event detection systems to predict subsequent claims. J Healthc Risk Manag. 2015;34(4):7-17. doi:10.1002/jhrm.21167. https://psnet.ahrq.gov/…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45617/psn-pdf
    November 30, 2016 - Walking a tightrope: balancing the risk of diagnostic error in inpatient pediatrics. November 30, 2016 Berkwitt A, Osborn R, Grossman M. Walking a Tightrope: Balancing the Risk of Diagnostic Error in Inpatient Pediatrics. Hosp Pediatr. 2016;6(9):566-8. doi:10.1542/hpeds.2016-0043. https://psnet.ahrq.gov/issue/walk…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34055/psn-pdf
    March 07, 2005 - What is driving hospitals' patient-safety efforts? March 7, 2005 Devers KJ, Pham HH, Liu G. What is driving hospitals' patient-safety efforts? Health Aff (Millwood). 2004;23(2):103-15. https://psnet.ahrq.gov/issue/what-driving-hospitals-patient-safety-efforts This study evaluated the role professionalism, regulati…

  18. Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
    January 01, 2023 - The subsequent lack of consistent communication identifying this complication and the associated plan

  19. Standard Deviations | PSNet

    psnet.ahrq.gov/web-mm/standard-deviations
    January 01, 2006 - Missed Appendicitis June 1, 2003 Perspective Identifying

  20. Primers | PSNet

    psnet.ahrq.gov/primers-0
    March 15, 2025 - Primers Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts. Latest Primers Clinical Decision Support Systems March…
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