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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33881/psn-pdf
    August 01, 2019 - In Conversation With… Erik Hollnagel, PhD June 1, 2019 In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd Editor's note: Dr. Hollnagel is Senior Professor of Patient Safety at the University of Jönköping (Sweden) as well as Visiting…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33816/psn-pdf
    October 01, 2016 - In Conversation With… Richard Platt, MD, MSc October 1, 2016 In Conversation With… Richard Platt, MD, MSc. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-richard-platt-md-msc Editor's note: Dr. Platt is Professor and Chair of the Harvard Medical School Department of Population Medicine. He…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841567/psn-pdf
    December 14, 2022 - Measuring Patient Safety December 14, 2022 Schreiber M, Van C, Mossburg SE. Measuring Patient Safety. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/measuring-patient-safety Following the landmark report To Err is Human: Building a Safer Health System, developed by the Institute of Medicine in 1999, pa…
  4. psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
    December 20, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable Citation Text: Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Ci…
  5. psnet.ahrq.gov/web-mm/workaround-error
    October 30, 2024 - Workaround Error Citation Text: Pape T. Workaround Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73078/psn-pdf
    September 19, 2024 - Risky Business: Creating Connections. July 17, 2024 Joseph B. Martin Conference Center, Boston, MA; September 19, 2024. https://psnet.ahrq.gov/issue/risky-business-creating-connections A core tenant of the patient safety improvement drawing from the experiences of various high-risk industries to address system saf…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46055/psn-pdf
    July 26, 2017 - Bridging the gap between work-as-imagined and work-as- done. July 26, 2017 Deutsch ES. PA-PSRS Patient Saf Advis. June 2017;14:80-83. https://psnet.ahrq.gov/issue/bridging-gap-between-work-imagined-and-work-done Understanding what is possible in the context of frontline practice is key when designing enhancements …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46553/psn-pdf
    October 25, 2017 - Telehealth. October 25, 2017 Tuckson R, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med. 2017;377(16):1585-1592. doi:10.1056/NEJMsr1503323. https://psnet.ahrq.gov/issue/telehealth Telemedicine can improve patient experience and access to health care. This commentary reviews the current state of telehealth practi…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60264/psn-pdf
    January 14, 2021 - COVID-19 Content. ISMP Medication Safety Alert! January 14, 2021 March 2020--January 2021. https://psnet.ahrq.gov/issue/special-editions-covid-19-ismp-medication-safety-alert Medication safety is improved through the sharing of frontline improvement experiences and concerns. These articles share recommendations to…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36815/psn-pdf
    March 28, 2011 - Implementation of a medication reconciliation process in an ambulatory internal medicine clinic. March 28, 2011 Nassaralla CL, Naessens JM, Chaudhry R, et al. Implementation of a medication reconciliation process in an ambulatory internal medicine clinic. Qual Saf Health Care. 2007;16(2):90-4. https://psnet.ahrq.g…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39182/psn-pdf
    May 22, 2019 - ACOG Committee Opinion No. 447: patient safety in obstetrics and gynecology. May 22, 2019 Improvement AC of O and GCC on PS and Q. ACOG Committee Opinion No. 447: Patient safety in obstetrics and gynecology. Obstet Gynecol. 2009;114(6):1424-7. doi:10.1097/AOG.0b013e3181c6f90e. https://psnet.ahrq.gov/issue/acog-com…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38252/psn-pdf
    November 26, 2008 - Hospital ethical climate and teamwork in acute care: the moderating role of leaders. November 26, 2008 Rathert C, Fleming DA. Hospital ethical climate and teamwork in acute care: the moderating role of leaders. Health Care Manag Rev. 2008;33(4):323-331. doi:10.1097/01.HCM.0000318769.75018.8d. https://psnet.ahrq.go…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44503/psn-pdf
    November 18, 2024 - Certified Professional in Patient Safety Review Course. November 18, 2024 Institute for Healthcare Improvement. February 5-6, 2025, 12:00-4:00 PM (eastern). https://psnet.ahrq.gov/issue/certified-professional-patient-safety-review-course This online class prepares individuals to apply for the Institute for Healthca…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45027/psn-pdf
    April 06, 2016 - Patient Safety 2030. April 6, 2016 Yu A, Flott K, Chainani N, Fontana G, Darzi A. London, UK: NIHR Imperial Patient Safety Translational Research Centre; 2016. https://psnet.ahrq.gov/issue/patient-safety-2030 Examining emerging trends in patient safety improvement work, this report recommends strategies and tools…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851927/psn-pdf
    August 02, 2023 - Perioperative Handoffs. August 2, 2023 Abraham J, Rosen M, Greilich PE eds. Jt Comm J Qual Patient Saf. 2023;49(8):341-434. https://psnet.ahrq.gov/issue/perioperative-handoffs Handoffs occur several times during a surgical procedure, increasing the risk of communication mistakes and misunderstandings. This special…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44678/psn-pdf
    July 05, 2017 - Patient Safety Risk Management Playbook. July 5, 2017 Chicago, IL: American Society for Healthcare Risk Management; 2015. https://psnet.ahrq.gov/issue/patient-safety-risk-management-playbook Proactive risk management is an important component to improving the safety of care. Exploring principles of high reliabilit…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44337/psn-pdf
    July 22, 2015 - Patient Safety Supplement. July 22, 2015 Middleton J, ed. Nursing Times and Health Service Journal. July 2015:s1-s20. https://psnet.ahrq.gov/issue/patient-safety-supplement Drawing from presentations at an annual conference in the United Kingdom, articles in this supplement discuss barcode technologies, the Sign u…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850935/psn-pdf
    June 21, 2023 - Non–operating room anesthesia challenges. June 21, 2023 Smith MJ. Anesthesiology News. June 6, 2023. https://psnet.ahrq.gov/issue/non-operating-room-anesthesia-challenges The use of office-based anesthesia presents both care improvements and risks for patients and clinical teams. This article summarizes frontline …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836867/psn-pdf
    April 06, 2022 - Safer Dx Checklist: 10 High-Priority Practices for Diagnostic Excellence. April 6, 2022 Houston TX;  Baylor College of Medicine: 2022. https://psnet.ahrq.gov/issue/safer-dx-checklist-10-high-priority-practices-diagnostic-excellence Assessment can identify the current state of a process or program to reveal ar…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73123/psn-pdf
    April 01, 2020 - Digital Healthcare Research. April 1, 2020 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/digital-healthcare-research An understanding of the impact that digital tools can have on clinical decision making, patient self-care, and health system improvement is still emerging. This website hi…

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