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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42701/psn-pdf
    June 27, 2018 - Improving reliability with root cause analysis. June 27, 2018 Latino RJ https://psnet.ahrq.gov/issue/improving-reliability-root-cause-analysis This article relates how root cause analysis, typically used after an adverse event, can be utilized as a proactive risk assessment tool to enhance reliability. https://ps…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36092/psn-pdf
    March 18, 2010 - Improving the safety of telephone or verbal orders. March 18, 2010 PA-PSRS Patient Saf Advis. 2006 Jun;3(2):1,3-7. https://psnet.ahrq.gov/issue/improving-safety-telephone-or-verbal-orders This article shares several examples of errors made while verbally communicating medication orders and includes recommendations…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37069/psn-pdf
    December 20, 2007 - Standardising wristbands improves patient safety. December 20, 2007 National Patient Safety Agency. Safer Practice Notice. July 2007;(24):1-2. https://psnet.ahrq.gov/issue/standardising-wristbands-improves-patient-safety This notice highlights the importance of standardizing wristband design and information to make…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35320/psn-pdf
    September 14, 2005 - How business intelligence can improve patient safety. September 14, 2005 Wanless S, McManaway J. Metaphor Analytics. August 30, 2005. https://psnet.ahrq.gov/issue/how-business-intelligence-can-improve-patient-safety This article illustrates how hospitals can use their own administrative and patient data to reduce h…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865296/psn-pdf
    March 27, 2024 - National Patient Safety Goals March 27, 2024 Shaikh U. National Patient Safety Goals. PSNet [internet]. 2024. https://psnet.ahrq.gov/primer/national-patient-safety-goals Background Despite the development and publication of effective and evidence-based strategies to enhance patient safety and reduce preventable h…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33574/psn-pdf
    March 15, 2025 - Ambulatory Care Safety March 15, 2025 Ambulatory Care Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/ambulatory-care-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Las…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40077/psn-pdf
    July 10, 2012 - Improvement Cymru. July 10, 2012 NHS Wales. https://psnet.ahrq.gov/issue/improvement-cymru This national program draws from other large collaborative efforts to engage health care organizations across Wales in reducing preventable harm. It was rebranded from the 1000 Lives campaign in 2018. https://psnet.ahrq.gov…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35753/psn-pdf
    April 29, 2018 - IV vincristine survey shows safety improvements needed. April 29, 2018 ISMP Medication Safety Alert! Acute care edition. February 23, 2006. https://psnet.ahrq.gov/issue/iv-vincristine-survey-shows-safety-improvements-needed This article summarizes intravenous vincristine safety practices collected from more than 40…
  9. psnet.ahrq.gov/print/pdf/node/866984
    January 01, 2020 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Interdisciplinary teamwork Curated Library Foundations Medical teamwork and the evolution of safety science: a critical review. Neuhaus C, Lutnæs DE, Bergström J. Cogn Technol Work. 2020;22:13-27. In this narrative review, the authors contr…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35579/psn-pdf
    November 26, 2008 - Perioperative Issues for Surgeons: Improving Patient Safety and Outcomes. November 26, 2008 Napolitano LM, ed. Surg Clin North Am. 2005;85(6):1061-1380. https://psnet.ahrq.gov/issue/perioperative-issues-surgeons-improving-patient-safety-and-outcomes This issue focuses on the safety of surgical patients, with artic…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34582/psn-pdf
    November 15, 2011 - Improving Health Care. November 15, 2011 Schiff G https://psnet.ahrq.gov/issue/improving-health-care Quality and honesty play an influential role in the safety and cost of medical care. Gordon Schiff, the director of clinical and quality research (Department of Medicine at Stoger Hospital, Chicago, Illinois), exp…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34120/psn-pdf
    December 30, 2012 - Strategies for Hospitals to Improve Patient Safety: A Review of the Literature. December 30, 2012 Wong J, Beglaryan H. Toronto, ON: The Change Foundation; February 2004. https://psnet.ahrq.gov/issue/strategies-hospitals-improve-patient-safety-review-literature A literature review of preventable adverse events in a…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35491/psn-pdf
    July 12, 2018 - Battling the obstetric malpractice crisis: improving patient safety, part 1. July 12, 2018 Bernstein PS. Medscape Ob/Gyn. October 31, 2005. https://psnet.ahrq.gov/issue/battling-obstetric-malpractice-crisis-improving-patient-safety-part-1 The author emphasizes the complexity of decision making in obstetric care to…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33829/psn-pdf
    March 01, 2017 - Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety March 1, 2017 Singer SJ. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change…
  15. psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
    January 01, 2008 - In Conversation with…Jennifer Daley, MD January 1, 2008  Also Read an Essay Citation Text: In Conversation with…Jennifer Daley, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Co…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45858/psn-pdf
    March 24, 2017 - From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system. March 24, 2017 Austin M, Demski R, Callender T, et al. From Board to Bedside: How the Application of Financial Structures to Safety and Quality Can Drive Accountability i…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46471/psn-pdf
    March 20, 2018 - Diagnostic errors in primary care pediatrics: Project RedDE. March 20, 2018 Rinke ML, Singh H, Heo M, et al. Diagnostic Errors in Primary Care Pediatrics: Project RedDE. Acad Peds. 2018;18(2):220-227. doi:10.1016/j.acap.2017.08.005. https://psnet.ahrq.gov/issue/diagnostic-errors-primary-care-pediatrics-project-red…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40239/psn-pdf
    February 23, 2011 - Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach. February 23, 2011 Field T, Tjia J, Mazor KM, et al. Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach. Am J Med. 2011;124(2):179.e1-7. doi:10.1016/j.amjmed.2010.09.017. htt…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37842/psn-pdf
    November 20, 2017 - An epistemology of patient safety research: a framework for study design and interpretation. November 20, 2017 Brown C, Hofer T, Johal A, et al. An epistemology of patient safety research: a framework for study design and interpretation. Part 4. One size does not fit all. Quality and Safety in Health Care. 2008;17(…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46173/psn-pdf
    August 20, 2018 - Advances in Patient Safety and Medical Liability. August 20, 2018 Battles J, Azam I, Grady M, Reback K, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2017. AHRQ Publication No. 17-0017-EF. https://psnet.ahrq.gov/issue/advances-patient-safety-and-medical-liability This publication describes the re…

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