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  1. 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…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35588/psn-pdf
    February 03, 2011 - Creating a safer health care system: finding the constraint. February 3, 2011 Pauker SG, Zane EM, Salem D. Creating a safer health care system: finding the constraint. JAMA. 2005;294(22):2906-8. https://psnet.ahrq.gov/issue/creating-safer-health-care-system-finding-constraint This editorial builds on the discussi…
  3. 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…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37026/psn-pdf
    September 15, 2011 - Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents. September 15, 2011 Hayes CW, Rhee A, Detsky ME, et al. Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of inter…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45943/psn-pdf
    March 15, 2017 - Identifying and reducing complications after emergency room discharge. March 15, 2017 Hofmann PB, Bagian JP. Patient Saf Qual Healthc. February 20, 2017. https://psnet.ahrq.gov/issue/identifying-and-reducing-complications-after-emergency-room-discharge Emergency departments are complex environments that harbor fac…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50887/psn-pdf
    February 12, 2020 - Lessons learned from a systems approach to engaging patients and families in patient safety transformation. February 12, 2020 Hatlie MJ, Nahum A, Leonard R, et al. Lessons Learned from a Systems Approach to Engaging Patients and Families in Patient Safety Transformation. Jt Comm J Qual Patient Saf. 2020;46(3):158-1…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844989/psn-pdf
    February 22, 2023 - Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety. February 22, 2023 White A, Fulda KG, Blythe R, et al. Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety. Expert Opin D…
  8. 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…
  9. 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…
  10. 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…
  11. 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…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45772/psn-pdf
    January 11, 2017 - Technical Series on Safer Primary Care. January 11, 2017 Geneva, Switzerland: World Health Organization; 2016. https://psnet.ahrq.gov/issue/technical-series-safer-primary-care Much of patient safety research has focused on the hospital setting, but a majority of health care is delivered in the ambulatory setting. …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45570/psn-pdf
    December 07, 2016 - Getting the Board on Board: What Your Board Needs to Know About Quality and Safety, Third Edition. December 7, 2016 Oak Brook, IL; Joint Commission; 2016. ISBN: 9781599409412. https://psnet.ahrq.gov/issue/getting-board-board-what-your-board-needs-know-about-quality-and-safety- third-edition Engaging hospital lead…
  14. 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…
  15. 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…
  16. 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…
  17. 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. …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854835/psn-pdf
    October 25, 2023 - Improving patient safety by shifting power from health professionals to patients. October 25, 2023 BMJ. 2023(383):2219, 2278, 2319, 2331. https://psnet.ahrq.gov/issue/improving-patient-safety-shifting-power-health-professionals-patients This compendium of editorials and opinion pieces discuss “Martha’s Rule,” a ne…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863760/psn-pdf
    March 06, 2024 - Imagining improved interactions: patients' designs to address implicit bias. March 6, 2024 Yang C, Coney L, Mohanraj D, et al. AMIA Annu Symp Proc. 2023;2023:774-783. https://psnet.ahrq.gov/issue/imagining-improved-interactions-patients-designs-address-implicit-bias Implicit biases can compromise decision making a…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44314/psn-pdf
    November 06, 2015 - Unintentional discontinuation of chronic medications for seniors in nursing homes: evaluation of a national medication reconciliation accreditation requirement using a population-based cohort study. November 6, 2015 Stall NM, Fischer HD, Wu F, et al. Unintentional Discontinuation of Chronic Medications for Seniors…

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