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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/859350/psn-pdfDecember 20, 2023 - What are the experiences of team members involved in root cause analysis? A qualitative study. December 20, 2023 Willis R, Jones T, Hoiles J, et al. What are the experiences of team members involved in root cause analysis? A qualitative study. BMC Health Serv Res. 2023;23(1):1152. doi:10.1186/s12913-023-10164-9. h… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44246/psn-pdfNovember 15, 2016 - RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. November 15, 2016 Boston, MA: National Patient Safety Foundation; 2015. https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm The National Patient Safety Foundation issued these guidelines for improving root cause a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44350/psn-pdfJuly 29, 2015 - Reporting and using near-miss events to improve patient safety in diverse primary care practices: a collaborative approach to learning from our mistakes. July 29, 2015 Crane S, Sloane PD, Elder NC, et al. Reporting and Using Near-miss Events to Improve Patient Safety in Diverse Primary Care Practices: A Collaborat… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37960/psn-pdfSeptember 24, 2010 - A survey of the impact of disruptive behaviors and communication defects on patient safety. September 24, 2010 Rosenstein AH, O'Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf. 2008;34(8):464-471. https://psnet.ahrq.gov/issue/survey-i… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837502/psn-pdfJune 22, 2022 - Toward safer opioid prescribing in HIV care (TOWER): a mixed-methods, cluster-randomized trial. June 22, 2022 Cedillo G, George MC, Deshpande R, et al. Toward safer opioid prescribing in HIV care (TOWER): a mixed-methods, cluster-randomized trial. Addict Sci Clin Pract. 2022;17(1):28. doi:10.1186/s13722-022- 00311… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837023/psn-pdfMay 04, 2022 - Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity. May 4, 2022 Davidson C, Denning S, Thorp K, et al. Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity. BMJ Qual Saf. 2022;31(9):670-678. doi:10.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47853/psn-pdfApril 10, 2019 - Does a unit shift report "blackout" period improve patient safety? April 10, 2019 Olmstead J. Does a unit shift report "blackout" period improve patient safety? Nurs Manage. 2019;50(3):8- 10. doi:10.1097/01.NUMA.0000553500.85897.51. https://psnet.ahrq.gov/issue/does-unit-shift-report-blackout-period-improve-patien… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60637/psn-pdfJuly 01, 2020 - Impact of a pharmacist-administered deprescribing intervention on nursing home residents: a randomized controlled trial. July 1, 2020 Balsom C, Pittman N, King R, et al. Impact of a pharmacist-administered deprescribing intervention on nursing home residents: a randomized controlled trial. Int J Clin Pharm. 2020;4… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73376/psn-pdfJune 09, 2021 - Peer support by interprofessional health care providers in aftermath of patient safety incidents: a cross-sectional study. June 9, 2021 Vanhaecht K, Zeeman G, Schouten L, et al. Peer support by interprofessional health care providers in aftermath of patient safety incidents: a cross?sectional study. J Nurs Manag. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37113/psn-pdfMarch 24, 2011 - Mature rapid response system and potentially avoidable cardiopulmonary arrests in hospital. March 24, 2011 Galhotra S, DeVita MA, Simmons RL, et al. Mature rapid response system and potentially avoidable cardiopulmonary arrests in hospital. Qual Saf Health Care. 2007;16(4):260-265. https://psnet.ahrq.gov/issue/mat… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47883/psn-pdfMay 29, 2019 - Patient Safety in Obstetrics and Gynecology. May 29, 2019 Gluck PA, ed. Obstet Gynecol Clin North Am. 2019;46:H1-H8, 199-398. https://psnet.ahrq.gov/issue/patient-safety-obstetrics-and-gynecology Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. Articles in this speci… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60967/psn-pdfSeptember 30, 2020 - Electronic medical record-based interventions to encourage opioid prescribing best practices in the emergency department. September 30, 2020 Smalley CM, Willner MA, Muir MKR, et al. Electronic medical record-based interventions to encourage opioid prescribing best practices in the emergency department. Am J Emerg … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60660/psn-pdfJuly 09, 2020 - Pharmacist-led program to improve transitions from acute care to skilled nursing facility care. July 9, 2020 Achilleos M, McEwen J, Hoesly M, et al. Pharmacist-led program to improve transitions from acute care to skilled nursing facility care. Am J Health Syst Pharm. 2020;77(12). doi:10.1093/ajhp/zxaa090. https:/… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837599/psn-pdfJune 29, 2022 - Differences in medication reconciliation interventions between six hospitals: a mixed method study. June 29, 2022 Stuijt CCM, van den Bemt BJF, Boerlage VE, et al. Differences in medication reconciliation interventions between six hospitals: a mixed method study. BMC Health Serv Res. 2022;22(1):722. doi:10.1186/s12… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60707/psn-pdfJuly 22, 2020 - The devil is in the detail: how a closed-loop documentation system for IV infusion administration contributes to and compromises patient safety. July 22, 2020 Furniss D, Dean Franklin B, Blandford A. The devil is in the detail: how a closed-loop documentation system for IV infusion administration contributes to an… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36186/psn-pdfSeptember 30, 2010 - Findings of the first consensus conference on medical emergency teams. September 30, 2010 DeVita MA, Bellomo R, Hillman KM, et al. Findings of the First Consensus Conference on Medical Emergency Teams*. Crit Care Med. 2006;34(9). doi:10.1097/01.ccm.0000235743.38172.6e. https://psnet.ahrq.gov/issue/findings-first-c… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/867684/psn-pdfMarch 05, 2025 - Development of a preliminary patient safety classification system for generative AI. March 5, 2025 Hose B-Z, Handley JL, Biro J, et al. Development of a preliminary patient safety classification system for generative AI. BMJ Qual Saf. 2025;34(2):130-132. doi:10.1136/bmjqs-2024-017918. https://psnet.ahrq.gov/issue/… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866109/psn-pdfJune 12, 2024 - Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation improvement matrix. June 12, 2024 Bos K, van der Laan MJ, Groeneweg J, et al. Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation improvement matrix. BMJ Open Qual. 2024… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36632/psn-pdfJuly 28, 2010 - Operating room briefings and wrong-site surgery. July 28, 2010 Makary MA, Mukherjee A, Sexton B, et al. Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007;204(2):236-43. https://psnet.ahrq.gov/issue/operating-room-briefings-and-wrong-site-surgery Although wrong-site surgeries are rare, they have… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/851923/psn-pdfAugust 02, 2023 - Patient, carer and family experiences of seeking redress and reconciliation following a life-changing event: systematic review of qualitative evidence. August 2, 2023 Shaw L, Lawal HM, Briscoe S, et al. Patient, carer and family experiences of seeking redress and reconciliation following a life?changing event: sys…
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