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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45563/psn-pdf
    October 19, 2016 - Using a change model to reduce the risk of surgical site infection. October 19, 2016 Burden M. Using a change model to reduce the risk of surgical site infection. Br J Nurs. 2016;25(17):949- 955. https://psnet.ahrq.gov/issue/using-change-model-reduce-risk-surgical-site-infection Surgical site infections can resul…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60235/psn-pdf
    April 15, 2020 - Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust. April 15, 2020 NHS Improvement. Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust. NHS England. March 2020. https://psnet.ahrq.gov/issue/independent-morta…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35218/psn-pdf
    August 07, 2018 - Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety. August 7, 2018 Scobie S, Thomson R. London, UK : National Patient Safety Agency; 2005. https://psnet.ahrq.gov/issue/building-memory-preventing-harm-reducing-risks-and-improving-patient-safety Created in 2001 to institute changes in he…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74758/psn-pdf
    February 09, 2022 - Emotional harm in the radiology department: analysis of an underrecognized preventable error. February 9, 2022 Siewert B, Swedeen S, Brook OR, et al. Emotional harm in the radiology department: analysis of an underrecognized preventable error. Radiology. 2022;302(3):613-619. doi:10.1148/radiol.2021211846. https://…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46579/psn-pdf
    April 11, 2018 - Electronic medicine can send you test results quickly. But what if they're scary? April 11, 2018 Boodman SG. Washington Post. March 26, 2018. https://psnet.ahrq.gov/issue/electronic-medicine-can-send-you-test-results-quickly-what-if-theyre-scary Although providing patients with access to physician notes and test r…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46844/psn-pdf
    March 07, 2018 - Learning collaboratives: insights and a new taxonomy from AHRQ's two decades of experience. March 7, 2018 Nix M, McNamara P, Genevro J, et al. Learning Collaboratives: Insights And A New Taxonomy From AHRQ's Two Decades Of Experience. Health Aff (Millwood). 2018;37(2):205-212. doi:10.1377/hlthaff.2017.1144. https…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73065/psn-pdf
    March 24, 2021 - Implementing the clinical occurrence reporting and learning system: a double-loop learning incident reporting system in long-term care. March 24, 2021 Goh HS, Tan V, Chang J, et al. Implementing the clinical occurrence reporting and learning system: a double-loop learning incident reporting system in long-term car…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47305/psn-pdf
    March 19, 2019 - Effect of genetic diagnosis on patients with previously undiagnosed disease. March 19, 2019 Splinter K, Adams DR, Bacino CA, et al. Effect of Genetic Diagnosis on Patients with Previously Undiagnosed Disease. New Engl J Med. 2018;379(22):2131-2139. doi:10.1056/NEJMoa1714458. https://psnet.ahrq.gov/issue/effect-gen…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47568/psn-pdf
    March 06, 2019 - Trends in anesthesia-related liability and lessons learned. March 6, 2019 Mora JC, Kaye AD, Romankowski ML, et al. Trends in Anesthesia-Related Liability and Lessons Learned. Adv Anesth. 2018;36(1):231-249. doi:10.1016/j.aan.2018.07.009. https://psnet.ahrq.gov/issue/trends-anesthesia-related-liability-and-lessons-l…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851361/psn-pdf
    July 12, 2023 - Types and effects of feedback for emergency ambulance staff: a systematic mixed studies review and meta- analysis. July 12, 2023 Wilson C, Janes G, Lawton R, et al. Types and effects of feedback for emergency ambulance staff: a systematic mixed studies review and meta-analysis. BMJ Qual Saf. 2023;32(10):573-588. …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73107/psn-pdf
    April 07, 2021 - Crisis checklists in emergency medicine: another step forward for cognitive aids. April 7, 2021 Chen Y-YK, Arriaga AF. Crisis checklists in emergency medicine: another step forward for cognitive aids. BMJ Qual Saf. 2021;30(9):689-693. doi:10.1136/bmjqs-2021-013203. https://psnet.ahrq.gov/issue/crisis-checklists-em…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865704/psn-pdf
    May 01, 2024 - Supporting error management and safety climate in ambulatory care practices: the CIRSforte study. May 1, 2024 Müller BS, Lüttel D, Schütze D, et al. Supporting error management and safety climate in ambulatory care practices: the CIRSforte study. J Patient Saf. 2024;20(5):314-322. doi:10.1097/pts.0000000000001225. …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37294/psn-pdf
    May 21, 2013 - Improving Hand-Off Communication. May 21, 2013 Oakbrook Terrace lL: Joint Commission Resources; 2007. ISBN 9781599400907. https://psnet.ahrq.gov/issue/improving-hand-communication The process of transferring primary responsibility for patient care is commonly referred to as a handoff. Handoffs are inherently dange…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47589/psn-pdf
    January 09, 2019 - Framework for Effective Board Governance of Health System Quality. January 9, 2019 Daley Ullem E, Gandhi TK, Mate K, et al. IHI White Paper. Boston, MA: Institute for Healthcare Improvement; 2018. https://psnet.ahrq.gov/issue/framework-effective-board-governance-health-system-quality The role of hospital boards i…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45000/psn-pdf
    August 15, 2016 - Medicare and Medicaid Programs; Hospital and Critical Access Hospital (CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient Care; Proposed Rule. June 29, 2016 Centers for Medicare & Medicaid Services. Fed Regist. 2016;81:39447-39480. https://psnet.ahrq.gov/issue/medicare-and-medicaid-progra…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35220/psn-pdf
    May 14, 2015 - Patient Safety and Quality Improvement Act of 2005. May 14, 2015 Pub L No. 109-41.  https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005 This bill amends the Public Health Service Act to encourage a culture of safety in health care organizations. The bill, signed into law July 29, 2005…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46572/psn-pdf
    January 01, 2018 - Effects of efforts to optimise morbidity and mortality rounds to serve contemporary quality improvement and educational goals: a systematic review. December 21, 2017 Smaggus A, Mrkobrada M, Marson A, et al. Effects of efforts to optimise morbidity and mortality rounds to serve contemporary quality improvement and …
  18. psnet.ahrq.gov/issue/quality-special-issue
    April 13, 2022 - Special or Theme Issue Quality Special Issue. Citation Text: Quality Special Issue. J Med Imaging Radiat Oncol. 2022;66(2):165-309. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin …
  19. psnet.ahrq.gov/issue/can-wearable-tech-prevent-healthcare-errors
    December 02, 2020 - Newspaper/Magazine Article Can wearable tech prevent healthcare errors? Citation Text: Can wearable tech prevent healthcare errors? Reese SM. Information Week. March 11, 2014.  Copy Citation Save Save to your library Print Download PDF S…
  20. psnet.ahrq.gov/issue/why-hospitals-should-fly-ultimate-flight-plan-patient-safety-and-quality-care
    December 19, 2018 - Book/Report Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. Citation Text: Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. Nance JJ. Boseman, MT: Second River Healthcare Press; 2008. ISBN: 9780974386058. Copy…

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