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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74263/psn-pdf
    January 19, 2022 - "Some version, most of the time": the surgical safety checklist, patient safety, and the everyday experience of practice variation. January 19, 2022 Hammond Mobilio M, Paradis E, Moulton C-A. “Some version, most of the time”: The surgical safety checklist, patient safety, and the everyday experience of practice va…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837731/psn-pdf
    July 27, 2022 - Predictors and outcomes of patient safety culture: a cross-sectional comparative study. July 27, 2022 Mrayyan MT. Predictors and outcomes of patient safety culture: a cross-sectional comparative study. BMJ Open Qual. 2022;11(3):e001889. doi:10.1136/bmjoq-2022-001889. https://psnet.ahrq.gov/issue/predictors-and-out…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837794/psn-pdf
    August 10, 2022 - Combined impact of Medicare's hospital pay for performance programs on quality and safety outcomes is mixed. August 10, 2022 Waters TM, Burns N, Kaplan CM, et al. Combined impact of Medicare’s hospital pay for performance programs on quality and safety outcomes is mixed. BMC Health Serv Res. 2022;22(1):958. doi:1…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47240/psn-pdf
    March 06, 2019 - Improving detection of intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) and their contribution to postoperative outcomes. March 6, 2019 Chen Q, Rosen AK, Amirfarzan H, et al. Improving detection of intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) and their …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837594/psn-pdf
    June 29, 2022 - Machine learning models outperform manual result review for the identification of wrong blood in tube errors in complete blood count results. June 29, 2022 Farrell C?JL, Giannoutsos J. Machine learning models outperform manual result review for the identification of wrong blood in tube errors in complete blood cou…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866596/psn-pdf
    August 28, 2024 - Electronic Test Result Communication in the Era of the 21st Century Cures Act August 28, 2024 Bradford A, Ehsan S, Shahid U, et al. Electronic Test Result Communication In The Era Of The 21St Century Cures Act. Rockville, MD: Agency for Healthcare Research and Quality; July 2024. AHRQ Publication No. 24-0010-3-EF …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867381/psn-pdf
    December 18, 2024 - Promoting medication safety for older adults upon hospital discharge: guiding principles for a medication discharge plan. December 18, 2024 Zhang FH, Lauzon J, Payette J, et al. Promoting medication safety for older adults upon hospital discharge: guiding principles for a medication discharge plan. Br J Clin Pharm…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/860728/psn-pdf
    January 17, 2024 - Factors influencing second victim experiences and support needs of OB/GYN and pediatric healthcare professionals after adverse patient events. January 17, 2024 Rivera-Chiauzzi EY, Riggan KA, Huang L, et al. Factors influencing second victim experiences and support needs of OB/GYN and pediatric healthcare professio…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851061/psn-pdf
    June 28, 2023 - Learning from experience: a qualitative study of surgeons' perspectives on reporting and dealing with serious adverse events. June 28, 2023 Øyri SF, Søreide K, Søreide E, et al. Learning from experience: a qualitative study of surgeons’ perspectives on reporting and dealing with serious adverse events. BMJ Open Qu…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866808/psn-pdf
    September 25, 2024 - What is safety leadership? A systematic review of definitions. September 25, 2024 Adra I, Giga S, Hardy C, et al. What is safety leadership? A systematic review of definitions. J Safety Res. 2024;90:181-191. doi:10.1016/j.jsr.2024.04.001. https://psnet.ahrq.gov/issue/what-safety-leadership-systematic-review-defini…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843083/psn-pdf
    January 25, 2023 - Use of recalled devices in new device authorizations under the US Food and Drug Administration's 510(k) pathway and risk of subsequent recalls. January 25, 2023 Kramer DB, Yeh RW. Use of recalled devices in new device authorizations under the US Food and Drug Administration's 510(k) pathway and risk of subsequent …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60054/psn-pdf
    March 18, 2020 - Ensuring successful implementation of communication- and-resolution programmes. March 18, 2020 Mello MM, Roche S, Greenberg Y, et al. Ensuring successful implementation of communication-and- resolution programmes. BMJ Qual Saf. 2020;29(11):895-904. doi:10.1136/bmjqs-2019-010296. https://psnet.ahrq.gov/issue/ensuri…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45697/psn-pdf
    August 29, 2018 - Challenges of implementing a communication-and- resolution program where multiple organizations must cooperate. August 29, 2018 Mello MM, Armstrong S, Greenberg Y, et al. Challenges of Implementing a Communication-and-Resolution Program Where Multiple Organizations Must Cooperate. Health Serv Res. 2016;51 Suppl 3:…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865592/psn-pdf
    April 17, 2024 - Associations between organizational communication and patients' experience of prolonged emotional impact following medical errors. April 17, 2024 Sokol-Hessner L, Dechen T, Folcarelli P, et al. Associations between organizational communication and patients' experience of prolonged emotional impact following medica…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836807/psn-pdf
    March 30, 2022 - Preventing delayed and missed care by applying artificial intelligence to trigger radiology imaging follow-up. March 30, 2022 Domingo J, Galal G, Huang J. Preventing delayed and missed care by applying artificial intelligence to trigger radiology imaging follow-up. NEJM Catal Innov Care Deliv. 2022;3(4). https://p…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38491/psn-pdf
    January 31, 2011 - Diagnostic errors--The next frontier for patient safety. January 31, 2011 Newman-Toker DE, Pronovost P. Diagnostic errors--the next frontier for patient safety. JAMA. 2009;301(10):1060-2. doi:10.1001/jama.2009.249. https://psnet.ahrq.gov/issue/diagnostic-errors-next-frontier-patient-safety Studies from autopsy dat…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50795/psn-pdf
    January 15, 2020 - Diagnostic error in the emergency department: learning from national patient safety incident report analysis. January 15, 2020 Hussain F, Cooper A, Carson-Stevens A, et al. Diagnostic error in the emergency department: learning from national patient safety incident report analysis. BMC Emerg Med. 2019;19(1):77. doi…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41814/psn-pdf
    March 04, 2015 - Autopsy as a quality control measure for radiology, and vice versa. March 4, 2015 Murken DR, Ding M, Branstetter BF, et al. Autopsy as a quality control measure for radiology, and vice versa. AJR Am J Roentgenol. 2012;199(2):394-401. doi:10.2214/AJR.11.8386. https://psnet.ahrq.gov/issue/autopsy-quality-control-mea…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34690/psn-pdf
    February 10, 2011 - Systems analysis of adverse drug events. February 10, 2011 Leape L, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274(1):35-43. https://psnet.ahrq.gov/issue/systems-analysis-adverse-drug-events The authors report a "systems analysis" of the adverse drug…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50655/psn-pdf
    January 01, 2020 - Reflections on implementing a hospital-wide provider- based electronic inpatient mortality review system: lessons learnt. November 13, 2019 Mendu ML, Lu Y, Petersen A, et al. Reflections on implementing a hospital-wide provider-based electronic inpatient mortality review system: lessons learnt. BMJ Qual Saf. 2020;…
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