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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41082/psn-pdf
    January 27, 2012 - The effect of medication reconciliation in elderly patients at hospital discharge. January 27, 2012 Midlöv P, Bahrani L, Seyfali M, et al. The effect of medication reconciliation in elderly patients at hospital discharge. Int J Clin Pharm. 2012;34(1):113-9. doi:10.1007/s11096-011-9599-6. https://psnet.ahrq.gov/iss…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41035/psn-pdf
    January 04, 2012 - Extraneous tissue a potential source for diagnostic error in surgical pathology. January 4, 2012 Layfield LJ, Witt BL, Metzger KG, et al. Extraneous tissue: a potential source for diagnostic error in surgical pathology. Am J Clin Pathol. 2011;136(5):767-72. doi:10.1309/AJCP4FFSBPHAU8IU. https://psnet.ahrq.gov/issu…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35408/psn-pdf
    August 05, 2009 - Factors influencing preceptors' responses to medical errors: a factorial survey. August 5, 2009 Mazor KM, Fischer M, Haley H-L, et al. Factors influencing preceptors' responses to medical errors: a factorial survey. Acad Med. 2005;80(10 Suppl):S88-92. https://psnet.ahrq.gov/issue/factors-influencing-preceptors-res…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74195/psn-pdf
    December 15, 2021 - Technology, Education and Safety. December 15, 2021 Ruskin KJ, ed. Curr Opin Anaesthesiol. 2021;34(6):720-765 https://psnet.ahrq.gov/issue/technology-education-and-safety-0 Anesthesia services are high risk despite progress made in the specialty to improve its safety. This special section covers issues that affect…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39340/psn-pdf
    March 17, 2010 - Adverse Events in Hospitals: Methods for Identifying Events. March 17, 2010 Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; March 2010. Report No. OEI-06-08-00221. https://psnet.ahrq.gov/issue/adverse-events-hospitals-methods-identifying-events This report…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36316/psn-pdf
    October 26, 2010 - Improving self-reporting of adverse drug events in a West Virginia hospital. October 26, 2010 Schade CP, Hannah K, Ruddick P, et al. Improving self-reporting of adverse drug events in a West Virginia hospital. Am J Med Qual. 2006;21(5):335-41. https://psnet.ahrq.gov/issue/improving-self-reporting-adverse-drug-even…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47292/psn-pdf
    May 01, 2022 - Nebraska Coalition for Patient Safety Annual Report. May 1, 2022 Omaha, NE: Nebraska Coalition for Patient Safety; 2022. https://psnet.ahrq.gov/issue/nebraska-coalition-patient-safety-2018-annual-report Patient Safety Organizations (PSOs) provide local evidence to inform learning among their members. This annual r…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39068/psn-pdf
    October 28, 2009 - Four patients say Cedars-Sinai did not tell them they had received a radiation overdose. October 28, 2009 Zarembo A. https://psnet.ahrq.gov/issue/four-patients-say-cedars-sinai-did-not-tell-them-they-had-received-radiation- overdose This news piece describes communication gaps following a radiation overdose incid…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41086/psn-pdf
    January 25, 2012 - Cognitive errors detected in anaesthesiology: a literature review and pilot study. January 25, 2012 Stiegler MP, Neelankavil JP, Canales C, et al. Cognitive errors detected in anaesthesiology: a literature review and pilot study. Br J Anaesth. 2012;108(2):229-35. doi:10.1093/bja/aer387. https://psnet.ahrq.gov/issu…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40090/psn-pdf
    May 13, 2015 - Patient safety in geriatrics: a call for action. May 13, 2015 Tsilimingras D, Rosen AK, Berlowitz DR. Patient safety in geriatrics: a call for action. J Gerontol A Biol Sci Med Sci. 2003;58(9):M813-9. https://psnet.ahrq.gov/issue/patient-safety-geriatrics-call-action This review discusses medication errors and pat…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38557/psn-pdf
    April 22, 2009 - Antecedents of severe and nonsevere medication errors. April 22, 2009 Chang Y-K, Mark BA. Antecedents of severe and nonsevere medication errors. J Nurs Scholarsh. 2009;41(1):70-8. doi:10.1111/j.1547-5069.2009.01253.x. https://psnet.ahrq.gov/issue/antecedents-severe-and-nonsevere-medication-errors This study examin…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36879/psn-pdf
    June 13, 2011 - Medication Safety and Hospital Referrals: A Report by the Health and Disability Commissioner. June 13, 2011 Paterson R. Auckland, NZ; Office of the Health and Disability Commissioner: April 2007. https://psnet.ahrq.gov/issue/medication-safety-and-hospital-referrals-report-health-and-disability- commissioner …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45735/psn-pdf
    July 17, 2017 - CMPA Good Practices Guide. July 17, 2017 Ottawa, Ontario: Canadian Medical Protective Association; 2016. https://psnet.ahrq.gov/issue/cmpa-good-practices-guide Key patient safety topics include human factors, teamwork, adverse events, communication, professionalism, and risk management. This website provides resou…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38796/psn-pdf
    April 04, 2011 - A 62-year-old woman with skin cancer who experienced wrong-site surgery. April 4, 2011 Gallagher TH. A 62-year-old woman with skin cancer who experienced wrong-site surgery: review of medical error. JAMA. 2009;302(6):669-77. doi:10.1001/jama.2009.1011. https://psnet.ahrq.gov/issue/62-year-old-woman-skin-cancer-who…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42213/psn-pdf
    April 17, 2013 - Quality: performance improvement, teamwork, information technology and protocols. April 17, 2013 Coleman NE, Pon S. Quality: performance improvement, teamwork, information technology and protocols. Crit Care Clin. 2013;29(2):129-51. doi:10.1016/j.ccc.2012.11.002. https://psnet.ahrq.gov/issue/quality-performance-im…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46442/psn-pdf
    October 04, 2017 - Handoff Communication. October 4, 2017 APSF Newsletter. October 2017;32:29-56. https://psnet.ahrq.gov/issue/handoff-communication Handoff processes are known to carry risks of communication errors. This special issue focuses on transfers involving anesthesia care. Articles review different types of handoffs, chara…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45075/psn-pdf
    May 18, 2019 - NHS Improvement. May 18, 2019 NHS England. https://psnet.ahrq.gov/issue/nhs-improvement The National Health Service (NHS) has been a global leader in patient safety improvement since the publication of An Organization With a Memory in 2000. This government resource combines several NHS initiatives—such as the Nat…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46280/psn-pdf
    December 03, 2018 - Lost Mothers: Maternal Care and Preventable Deaths. December 3, 2018 New York, NY: ProPublica, Inc; 2017-2020. https://psnet.ahrq.gov/issue/lost-mothers-maternal-care-and-preventable-deaths Maternal mortality is a sentinel event that affects mothers and families across a wide range of socioeconomic characteristics…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37500/psn-pdf
    January 30, 2008 - The prevalence of wrong level surgery among spine surgeons. January 30, 2008 Mody MG, Nourbakhsh A, Stahl DL, et al. The prevalence of wrong level surgery among spine surgeons. Spine (Phila Pa 1976). 2008;33(2):194-198. doi:10.1097/BRS.0b013e31816043d1. https://psnet.ahrq.gov/issue/prevalence-wrong-level-surgery-a…

  20. Surprise Wire | PSNet

    psnet.ahrq.gov/web-mm/surprise-wire
    July 15, 2020 - Surprise Wire Citation Text: Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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