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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38332/psn-pdf
    January 14, 2009 - Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback. January 14, 2009 Garnerin P, Arès M, Huchet A, et al. Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback. Qual Saf Health Care. 2008;17(6):454-8. doi:10.11…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40546/psn-pdf
    September 29, 2017 - Tragedy into policy: a quantitative study of nurses' attitudes toward patient advocacy activities. September 29, 2017 Black LM. Tragedy into policy: a quantitative study of nurses' attitudes toward patient advocacy activities. Am J Nurs. 2011;111(6):26-37. doi:10.1097/01.NAJ.0000398537.06542.c0. https://psnet.ahrq…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72478/psn-pdf
    November 18, 2020 - The impact of the use of employee functional flexibility on patient safety. November 18, 2020 Salvador RO, Gnanlet A, McDermott C. The impact of the use of employee functional flexibility on patient safety. Personnel Rev. 2020;50(3):971-984. doi:10.1108/pr-10-2019-0562. https://psnet.ahrq.gov/issue/impact-use-empl…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852464/psn-pdf
    August 16, 2023 - Notice of Intent to Publish Funding Opportunity Announcements to Understand and Improve Diagnostic Safety in Ambulatory Care. August 16, 2023 Rockville, MD: Agency for Research and Quality; July 27, 2023. Notice Number NOT-HS-23-018. https://psnet.ahrq.gov/issue/notice-intent-publish-funding-opportunity-announceme…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43810/psn-pdf
    March 15, 2016 - Partnering with VA stakeholders to develop a comprehensive patient safety data display: lessons learned from the field. March 15, 2016 Chen Q, Shin MH, Chan J, et al. Partnering With VA Stakeholders to Develop a Comprehensive Patient Safety Data Display: Lessons Learned From the Field. Am J Med Qual. 2016;31(2):17…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/839322/psn-pdf
    November 02, 2022 - A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis. November 2, 2022 Roberts TJ, Sellars MC, Sands JM, et al. A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis. JCO Oncol Pract. 2022;18(12):833-839. doi:10.…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50708/psn-pdf
    December 04, 2019 - Identifying medication errors in neonatal intensive care units: a two-center study December 4, 2019 Eslami K, Aletayeb F, Aletayeb SMH, et al. Identifying medication errors in neonatal intensive care units: a two-center study. BMC Pediatr. 2019;19(1):365. doi:10.1186/s12887-019-1748-4. https://psnet.ahrq.gov/issue…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48059/psn-pdf
    June 05, 2019 - Investigating for improvement? Five strategies to ensure national patient safety investigations improve patient safety. June 5, 2019 Macrae C. Investigating for improvement? Five strategies to ensure national patient safety investigations improve patient safety. J R Soc Med. 2019;112(9):365-369. doi:10.1177/014107…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46707/psn-pdf
    October 13, 2018 - Medication errors involving nursing students: a systematic review. October 13, 2018 Asensi-Vicente J, Jiménez-Ruiz I, Vizcaya-Moreno F. Medication Errors Involving Nursing Students: A Systematic Review. Nurse Educ. 2018;43(5):E1-E5. doi:10.1097/NNE.0000000000000481. https://psnet.ahrq.gov/issue/medication-errors-i…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46637/psn-pdf
    December 06, 2017 - Instituting vincristine minibag administration: an innovative strategy using simulation to enhance chemotherapy safety. December 6, 2017 Corbitt N, Malick L, Nishioka J, et al. Instituting Vincristine Minibag Administration: An Innovative Strategy Using Simulation to Enhance Chemotherapy Safety. J Infus Nurs. 2017…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45702/psn-pdf
    January 25, 2017 - Implantable infusion pumps in the magnetic resonance (MR) environment: FDA safety communication—important safety precautions. January 25, 2017 MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 11, 2017. https://psnet.ahrq.gov/issue/implantable-infusion-pumps-magnetic-resonance-mr-e…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43981/psn-pdf
    April 22, 2015 - National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac surgery: error cycles precede ?85% of patient deaths. April 22, 2015 Hickey EJ, Nosikova Y, Pham-Hung E, et al. National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac sur…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39600/psn-pdf
    June 16, 2010 - Developing a patient safety surveillance system to identify adverse events in the intensive care unit. June 16, 2010 Stockwell DC, Kane-Gill SL. Developing a patient safety surveillance system to identify adverse events in the intensive care unit. Crit Care Med. 2010;38(6 Suppl):S117-25. doi:10.1097/CCM.0b013e3181d…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60060/psn-pdf
    March 18, 2020 - The benefits and burdens of working with patient safety organizations under the Patient Safety and Quality Improvement Act of 2005. March 18, 2020 Dwyer PE, Watts CD. The benefits and burdens of working with patient safety organizations under the Patient Safety and Quality Improvement Act of 2005. J Health Life Sc…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39621/psn-pdf
    June 23, 2010 - Defining near misses: towards a sharpened definition based on empirical data about error handling processes. June 23, 2010 Kessels-Habraken M, Van der Schaaf T, De Jonge J, et al. Defining near misses: towards a sharpened definition based on empirical data about error handling processes. Soc Sci Med. 2010;70(9):130…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48011/psn-pdf
    May 29, 2019 - Is it time for safeguards in the adoption of robotic surgery? May 29, 2019 Sheetz KH, Dimick JB. Is It Time for Safeguards in the Adoption of Robotic Surgery? JAMA. 2019;321(20):1971-1972. doi:10.1001/jama.2019.3736. https://psnet.ahrq.gov/issue/it-time-safeguards-adoption-robotic-surgery The FDA recently raised …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60359/psn-pdf
    May 20, 2020 - Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. May 20, 2020 ISMP Medication Safety Alert! Acute care edition. May 7, 2020;25(9). https://psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone- overdose Lack of familiarity with sm…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73373/psn-pdf
    January 01, 2022 - State medical board regulation of compounding in physician offices. June 9, 2021 Reynolds KA, Hellquist K, Ibrahim SA, et al. State medical board regulation of compounding in physician offices. Arch Dermatol Res. 2022;314(4):363-367. doi:10.1007/s00403-021-02237-8. https://psnet.ahrq.gov/issue/state-medical-board-…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46777/psn-pdf
    January 24, 2018 - Safety analysis over time: seven major changes to adverse event investigation. January 24, 2018 Vincent CA, Carthey J, Macrae C, et al. Safety analysis over time: seven major changes to adverse event investigation. Implementation Science. 2017;12(1). doi:10.1186/s13012-017-0695-4. https://psnet.ahrq.gov/issue/safe…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837894/psn-pdf
    August 24, 2022 - Identifying boundary spanning reporter roles in patient safety events. August 24, 2022 Hurley VB, Boxley C, Sloss EA, et al. Identifying boundary spanning reporter roles in patient safety events. J Patient Saf Risk Manag. 2022;27(4):181-187. doi:10.1177/25160435221103096. https://psnet.ahrq.gov/issue/identifying-b…
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