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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43269/psn-pdf
    July 28, 2014 - Restoring trust in VA health care. July 28, 2014 Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med. 2014;371(4):295-297. doi:10.1056/NEJMp1406852. https://psnet.ahrq.gov/issue/restoring-trust-va-health-care In response to a recent investigation raising concerns about inaccurate reporting of wait-ti…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47387/psn-pdf
    September 12, 2018 - Guideline implementation: team communication. September 12, 2018 Link T. Guideline Implementation: Team Communication: 1.8 www.aornjournal.org/content/cme. AORN J. 2018;108(2):165-177. doi:10.1002/aorn.12300. https://psnet.ahrq.gov/issue/guideline-implementation-team-communication Although team development has rec…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47412/psn-pdf
    October 31, 2018 - The systems approach at the sharp end. October 31, 2018 Cross SRH. The systems approach at the sharp end. Future Healthc J. 2019;5(3):176-180. doi:10.7861/futurehosp.5-3-176. https://psnet.ahrq.gov/issue/systems-approach-sharp-end Systems solutions are often focused on creating improvements at the organizational o…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45363/psn-pdf
    September 14, 2016 - Effective perioperative communication to enhance patient care. September 14, 2016 Garrett H. Effective Perioperative Communication to Enhance Patient Care. AORN J. 2016;104(2):111-20. doi:10.1016/j.aorn.2016.06.001. https://psnet.ahrq.gov/issue/effective-perioperative-communication-enhance-patient-care Poor team …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47712/psn-pdf
    February 20, 2019 - A cognitive forcing tool to mitigate cognitive bias—a randomised control trial. February 20, 2019 O'Sullivan ED, Schofield SJ. A cognitive forcing tool to mitigate cognitive bias - a randomised control trial. BMC Med Educ. 2019;19(1):12. doi:10.1186/s12909-018-1444-3. https://psnet.ahrq.gov/issue/cognitive-forcing…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45930/psn-pdf
    April 26, 2017 - A boy's life is lost to sepsis. Thousands are saved in his wake. April 26, 2017 Dwyer J. New York Times. April 13, 2017. https://psnet.ahrq.gov/issue/boys-life-lost-sepsis-thousands-are-saved-his-wake Stories of patient harm due to medical mistakes can serve as catalysts for organizational improvement. This newsp…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45303/psn-pdf
    June 15, 2017 - The global burden of diagnostic errors in primary care. June 15, 2017 Singh H, Schiff G, Graber ML, et al. The global burden of diagnostic errors in primary care. BMJ Qual Saf. 2017;26(6):484-494. doi:10.1136/bmjqs-2016-005401. https://psnet.ahrq.gov/issue/global-burden-diagnostic-errors-primary-care The need to i…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47114/psn-pdf
    October 13, 2018 - Focused ethnography of diagnosis in academic medical centers. October 13, 2018 Chopra V, Harrod M, Winter S, et al. Focused Ethnography of Diagnosis in Academic Medical Centers. J Hosp Med. 2018;13(10):668-672. doi:10.12788/jhm.2966. https://psnet.ahrq.gov/issue/focused-ethnography-diagnosis-academic-medical-cente…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45477/psn-pdf
    October 05, 2016 - Promoting safety through well-being: an experience in healthcare. October 5, 2016 Bruno A, Bracco F. Promoting Safety through Well-Being: An Experience in Healthcare. Front Psychol. 2016;7:1208. doi:10.3389/fpsyg.2016.01208. https://psnet.ahrq.gov/issue/promoting-safety-through-well-being-experience-healthcare Th…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38929/psn-pdf
    April 01, 2010 - Effectiveness of patient care teams and the role of clinical expertise and coordination: a literature review. April 1, 2010 Bosch M, Faber MJ, Cruijsberg J, et al. Review article: Effectiveness of patient care teams and the role of clinical expertise and coordination: a literature review. Med Care Res Rev. 2009;66(…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836871/psn-pdf
    April 06, 2022 - The spectrum of harm associated with modern medicine. April 6, 2022 Schattner A. The spectrum of harm associated with modern medicine. J Gen Intern Med. 2022;37(3):664- 667. doi:10.1007/s11606-021-06997-x. https://psnet.ahrq.gov/issue/spectrum-harm-associated-modern-medicine Interest in harm resulting from medical…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44442/psn-pdf
    August 26, 2015 - How your hospital can make you sick. August 26, 2015 Consumer Reports. July 29, 2015. https://psnet.ahrq.gov/issue/how-your-hospital-can-make-you-sick This news article reports on health care–associated infections, particularly Clostridium difficile and methicillin-resistant Staphylococcus aureus, discusses ways h…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73359/psn-pdf
    June 02, 2020 - Patient Safety Movement Foundation. June 2, 2020 15642 Sand Canyon Ave. #51268, Irvine, CA 92619. 877-236-0279, info@psmf.org. https://psnet.ahrq.gov/issue/patient-safety-movement-foundation This organization shares best practices to align and optimize efforts toward eliminating patient harm by the …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73543/psn-pdf
    July 28, 2021 - AMC PSO Resource Center. July 28, 2021 Academic Medical Center Patient Safety Organization. https://psnet.ahrq.gov/issue/amc-pso-resource-center Patient Safety organizations (PSO) are in a unique position to educate their members and the larger community on patient safety challenges. This PSO resource collection i…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72515/psn-pdf
    January 15, 2025 - AHRQ’s Surveys on Patient Safety Culture® Program: An Overview for New Users. December 17, 2024 Rockville, MD: Agency for Healthcare Research and Quality. January 15, 2025. https://psnet.ahrq.gov/issue/tutorial-ahrq-sopsr-data-entry-and-analysis-tool An organization’s understanding of its culture is foundational t…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43898/psn-pdf
    February 11, 2015 - Special Section on Patient Safety and Quality in Healthcare. February 11, 2015 Andersen HB, Lipczak H, Borch-Johnsen K, eds. Cogn Technol Work. 2015;17:1-155. https://psnet.ahrq.gov/issue/special-section-patient-safety-and-quality-healthcare Articles in this special issue explore patient safety from a sociotechnic…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46698/psn-pdf
    February 07, 2018 - Enhancing the quality and safety of the perioperative patient. February 7, 2018 Staender S, Smith A. Enhancing the quality and safety of the perioperative patient. Curr Opin Anaesthesiol. 2017;30(6):730-735. doi:10.1097/ACO.0000000000000517. https://psnet.ahrq.gov/issue/enhancing-quality-and-safety-perioperative-p…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48111/psn-pdf
    July 10, 2019 - Medication Safety in Key Action Areas. July 10, 2019 Geneva, Switzerland: World Health Organization; 2019. https://psnet.ahrq.gov/issue/medication-safety-key-action-areas Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores key areas of concern that require act…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45386/psn-pdf
    November 23, 2016 - Balancing doctor egos and errors. November 23, 2016 Sweeney JF. Medical Economics. November 10, 2016. https://psnet.ahrq.gov/issue/balancing-doctor-egos-and-errors Disclosure and candor with patients after a medical error has gained support from organizations, clinicians, and patients. This magazine article discus…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37895/psn-pdf
    July 09, 2008 - Accidents, claiming, and regional subcultures: are medical errors and malpractice lawsuits related to social capital? July 9, 2008 Williams J. Accidents, claiming, and regional subcultures: Are medical errors and malpractice lawsuits related to social capital? J Safety Res. 2008;39(3). doi:10.1016/j.jsr.2008.01.00…

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