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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39505/psn-pdf
    November 26, 2014 - Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit. November 26, 2014 O'Leary KJ, Wayne DB, Haviley C, et al. Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit. J Gen Intern Med. 2010;25(8):826-32. doi:10.1007/s11606-010-1345-6. h…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844792/psn-pdf
    January 01, 2020 - Surgical data recording technology: a solution to address medical errors? September 18, 2019 Shah NA, Jue J, Mackey T. Surgical Data Recording Technology. Ann Surg. 2020;271(3):431-433. doi:10.1097/sla.0000000000003510. https://psnet.ahrq.gov/issue/surgical-data-recording-technology-solution-address-medical-errors…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39498/psn-pdf
    February 10, 2015 - The effect of health information technology on quality in U.S. hospitals. February 10, 2015 McCullough JS, Casey M, Moscovice I, et al. The effect of health information technology on quality in U.S. hospitals. Health Aff (Millwood). 2010;29(4):647-654. doi:10.1377/hlthaff.2010.0155. https://psnet.ahrq.gov/issue/ef…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42880/psn-pdf
    January 22, 2014 - Applying ethnography to the study of context in healthcare quality and safety. January 22, 2014 Leslie M, Paradis E, Gropper MA, et al. Applying ethnography to the study of context in healthcare quality and safety. BMJ Qual Saf. 2014;23(2):99-105. doi:10.1136/bmjqs-2013-002335. https://psnet.ahrq.gov/issue/applyin…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36367/psn-pdf
    April 11, 2011 - Emergency medical services system changes reduce pediatric epinephrine dosing errors in the prehospital setting. April 11, 2011 Kaji AH, Gausche-Hill M, Conrad H, et al. Emergency medical services system changes reduce pediatric epinephrine dosing errors in the prehospital setting. Pediatrics. 2006;118(4):1493-150…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42128/psn-pdf
    August 15, 2013 - Computerized prescriber order entry and opportunities for medication errors: comparison to tradition paper- based order entry. August 15, 2013 Jozefczyk KG, Kennedy WK, Lin MJ, et al. Computerized prescriber order entry and opportunities for medication errors: comparison to tradition paper-based order entry. J Pha…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844553/psn-pdf
    February 15, 2023 - Mental health conditions leading cause of pregnancy- related deaths. February 15, 2023 Quick Safety. January 16 2023;(67):1-3. https://psnet.ahrq.gov/issue/mental-health-conditions-leading-cause-pregnancy-related-deaths Maternal safety is compromised by a range of social, cognitive, and clinical factors. This arti…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39458/psn-pdf
    April 12, 2011 - Hospital admission medication reconciliation in medically complex children: an observational study. April 12, 2011 Stone BL, Boehme S, Mundorff MB, et al. Hospital admission medication reconciliation in medically complex children: an observational study. Arch Dis Child. 2009. doi:10.1136/adc.2009.167528. https://p…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45927/psn-pdf
    April 12, 2017 - How redesigning the abrasive alarms of hospital soundscapes can save lives. April 12, 2017 Couch C. Fast Company. April 3, 2017. https://psnet.ahrq.gov/issue/how-redesigning-abrasive-alarms-hospital-soundscapes-can-save-lives Alarm frequency can contribute to distractions and stress in the hospital environment. Re…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35485/psn-pdf
    May 27, 2011 - Navigating the information technology highway: computer solutions to reduce errors and enhance patient safety. May 27, 2011 Koshy R. Navigating the information technology highway: computer solutions to reduce errors and enhance patient safety. Transfusion (Paris). 2005;45(4 Suppl):189S-205S. https://psnet.ahrq.go…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45933/psn-pdf
    March 08, 2017 - Bad hospital design is making us sicker. March 8, 2017 Khullar D. New York Times. February 22, 2017. https://psnet.ahrq.gov/issue/bad-hospital-design-making-us-sicker Implementing design changes in care environments can improve patient safety. This newspaper article reports on how efforts to address hospital desig…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46043/psn-pdf
    April 05, 2017 - High-reliability and the I-PASS communication tool. April 5, 2017 Clements K. High-reliability and the I-PASS communication tool. Nursing Management (Springhouse). 2017;48(3). doi:10.1097/01.numa.0000512897.68425.e5. https://psnet.ahrq.gov/issue/high-reliability-and-i-pass-communication-tool High reliability has y…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47512/psn-pdf
    February 20, 2019 - Framing the challenges of artificial intelligence in medicine. February 20, 2019 Yu K-H, Kohane IS. Framing the challenges of artificial intelligence in medicine. BMJ Qual Saf. 2019;28(3):238-241. doi:10.1136/bmjqs-2018-008551. https://psnet.ahrq.gov/issue/framing-challenges-artificial-intelligence-medicine Use o…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39898/psn-pdf
    February 01, 2011 - Improving reliability of clinical care practices for ventilated patients in the context of a patient safety improvement initiative. February 1, 2011 Pinto A, Burnett S, Benn J, et al. Improving reliability of clinical care practices for ventilated patients in the context of a patient safety improvement initiative.…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38211/psn-pdf
    May 21, 2009 - Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study. May 21, 2009 Morriss FH, Abramowitz PW, Nelson S, et al. Effectiveness of a barcode medication administration system in reducing preventable adverse…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40235/psn-pdf
    May 11, 2011 - Assessing and improving safety climate in a large cohort of intensive care units. May 11, 2011 Sexton B, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Med. 2011;39(5):934-9. doi:10.1097/CCM.0b013e318206d26c. https://psnet.ahrq.gov/iss…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41969/psn-pdf
    July 02, 2014 - The creation and impact of a dedicated section on quality and patient safety in a clinical academic department. July 2, 2014 Boudreaux AM, Vetter TR. The Creation and Impact of a Dedicated Section on Quality and Patient Safety in a Clinical Academic Department. Academic Medicine. 2012;88(2). doi:10.1097/acm.0b013e3…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36226/psn-pdf
    August 30, 2006 - Framework for a High Performance Health System for the United States. August 30, 2006 Mongan JJ. New York, NY; The Commonwealth Fund: 2006. https://psnet.ahrq.gov/issue/framework-high-performance-health-system-united-states This report calls for providing "safe, well-coordinated, accessible, and efficient" care th…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74143/psn-pdf
    December 01, 2021 - Confronting Racism in Health Care: Moving from Proclamations to New Practices. December 1, 2021 Hostetter M, Klein S. New York, NY: Commonwealth Fund;  October 18, 2021 https://psnet.ahrq.gov/issue/confronting-racism-health-care-moving-proclamations-new-practices Structural racism affects the safety and equit…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848384/psn-pdf
    May 03, 2023 - Roadmap to Health Care Safety for Massachusetts. May 3, 2023 Massachusetts Healthcare Safety and Quality Consortium. Boston, MA: Betsy Lehman Center for Patient Safety; April 2023. https://psnet.ahrq.gov/issue/roadmap-health-care-safety-massachusetts Collective engagement and focus are required to attain large sys…

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