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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46244/psn-pdfJune 28, 2017 - Changing the narratives for patient safety. June 28, 2017 Pronovost P, Sutcliffe K, Basu L, et al. Changing the narratives for patient safety. Bull World Health Organ. 2017;95(6):478-480. doi:10.2471/BLT.16.178392. https://psnet.ahrq.gov/issue/changing-narratives-patient-safety Mental models represent established … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38907/psn-pdfJanuary 03, 2017 - Applying Toyota Production System principles to a psychiatric hospital: making transfers safer and more timely. January 3, 2017 Young JQ, Wachter R. Applying Toyota Production System principles to a psychiatric hospital: making transfers safer and more timely. Jt Comm J Qual Patient Saf. 2009;35(9):439-448. https… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73894/psn-pdfFebruary 22, 2022 - Achieving Excellence in Cancer Diagnosis: Proceedings of a Workshop—in Brief. February 22, 2022 National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022. https://psnet.ahrq.gov/issue/achieving-excellence-cancer-diagnosis Diagnostic errors remain an o… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/48067/psn-pdfJune 12, 2019 - Maternal sleepiness and risk of infant drops in the postpartum period. June 12, 2019 Bittle MD, Knapp H, Polomano RC, et al. Maternal Sleepiness and Risk of Infant Drops in the Postpartum Period. Jt Comm J Qual Patient Saf. 2019;45(5):337-347. doi:10.1016/j.jcjq.2018.12.001. https://psnet.ahrq.gov/issue/maternal-s… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45315/psn-pdfSeptember 07, 2016 - Healthcare professionals' views on feedback of a patient safety culture assessment. September 7, 2016 Zwijnenberg NC, Hendriks M, Hoogervorst-Schilp J, et al. Healthcare professionals' views on feedback of a patient safety culture assessment. BMC Health Serv Res. 2016;16:199. doi:10.1186/s12913-016-1404-8. https:/… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44863/psn-pdfJuly 01, 2016 - Rating the raters: the inconsistent quality of health care performance measurement. July 1, 2016 Shahian DM, Normand S-LT, Friedberg MW, et al. Rating the Raters: The Inconsistent Quality of Health Care Performance Measurement. Ann Surg. 2016;264(1):36-8. doi:10.1097/SLA.0000000000001631. https://psnet.ahrq.gov/is… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47684/psn-pdfMarch 20, 2019 - The impact of mobile technology on teamwork and communication in hospitals: a systematic review. March 20, 2019 Martin G, Khajuria A, Arora S, et al. The impact of mobile technology on teamwork and communication in hospitals: a systematic review. J Am Med Inform Assoc. 2019;26(4):339-355. doi:10.1093/jamia/ocy175. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40550/psn-pdfJune 22, 2011 - Applying a multidisciplinary approach to the selection, evaluation, and acquisition of smart infusion pumps. June 22, 2011 Namshirin P. Applying a multidisciplinary approach to the selection, evaluation, and acquisition of smart infusion pumps. . J Med Bio Eng. 2011;31(2):93-98. doi:10.5405/jmbe.839. https://psnet… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60008/psn-pdfJuly 09, 2024 - IHI Patient Safety Congress. July 9, 2024 Institute for Healthcare Improvement. San Diego, CA, March 10-11, 2025. https://psnet.ahrq.gov/issue/ihi-patient-safety-congress This annual conference will host pre-session workshops, panels, and presentations covering a variety of patient safety topics that ali… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44300/psn-pdfJuly 29, 2015 - Learning From Serious Failings in Care: Main Report. July 29, 2015 Short-Life Working Group on Hospital Reports. Edinburgh, Scotland: Academy of Medical Royal Colleges and Faculties in Scotland; May 2015. https://psnet.ahrq.gov/issue/learning-serious-failings-care-main-report Substantive reports of failures have t… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/851461/psn-pdfJuly 19, 2023 - Patient safety 2.0: slaying dragons, not just investigating them. July 19, 2023 Card AJ. Patient safety 2.0: slaying dragons, not just investigating them. J Patient Saf. 2023;19(6):394-395. doi:10.1097/pts.0000000000001140. https://psnet.ahrq.gov/issue/patient-safety-20-slaying-dragons-not-just-investigating-them … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866169/psn-pdfJune 19, 2024 - Safe and equitable pediatric clinical use of AI. June 19, 2024 Handley JL, Lehmann CU, Ratwani RM. Safe and equitable pediatric clinical use of AI. JAMA Pediatr. 2024;178(7):637-638. doi:10.1001/jamapediatrics.2024.0897. https://psnet.ahrq.gov/issue/safe-and-equitable-pediatric-clinical-use-ai Accepting shared res… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46963/psn-pdfApril 18, 2018 - A Just Culture Guide. April 18, 2018 NHS Improvement. London, UK: National Health Service; March 15, 2018. https://psnet.ahrq.gov/issue/just-culture-guide Although focusing on system failure has been highlighted as key to improving patient safety, individual behaviors must also be recognized as contributors to ris… -
Spotlight (pdf file)
psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdfJanuary 01, 2021 - Spotlight Spotlight Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations Source and Credits • This presentation is based on the September 2021 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46478/psn-pdfMarch 27, 2018 - Promote a culture of safety with good catch reports. March 27, 2018 Wallace SC, Mamrol C, Finley E. PA-PSRS Patient Saf Advis. September 2017;14. https://psnet.ahrq.gov/issue/promote-culture-safety-good-catch-reports Near misses or good catches present organizations with learning opportunities. Using data compariso… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73569/psn-pdfAugust 04, 2021 - Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. August 4, 2021 Morris AH, Stagg B, Lanspa M, et al. Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/846164/psn-pdfMarch 15, 2023 - Crowding in the Emergency Department: Challenges for the Care of Children. March 15, 2023 Gross TK, Lane NE, Timm NL, et al. Crowding in the Emergency Department: Challenges for the Care of Children. Pediatrics. 2023;151(3):e2022060971-e2022060972. doi:10.1542/peds.2022-060971. https://psnet.ahrq.gov/issue/crowdin… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47344/psn-pdfSeptember 11, 2018 - Quality and Safety Between Ward and Board: a Biography of Artefacts Study. September 11, 2018 Keen J, Nicklin E, Long A, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2018. https://psnet.ahrq.gov/issue/quality-and-safety-between-ward-and-board-biography-artefacts-study The … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45564/psn-pdfOctober 03, 2017 - Fostering transparency in outcomes, quality, safety, and costs. October 3, 2017 Austin M, McGlynn EA, Pronovost P. Fostering Transparency in Outcomes, Quality, Safety, and Costs. JAMA. 2016;316(16):1661-1662. doi:10.1001/jama.2016.14039. https://psnet.ahrq.gov/issue/fostering-transparency-outcomes-quality-safety-a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/48141/psn-pdfJuly 24, 2019 - Evidence Brief: Implementation of High Reliability Organization Principles. July 24, 2019 Veazie S, Peterson K, Bourne D. Washington DC: United States Department of Veterans Affairs; May 2019. https://psnet.ahrq.gov/issue/evidence-brief-implementation-high-reliability-organization-principles This brief evalu…
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