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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46925/psn-pdf
    March 07, 2018 - Interventional procedures outside of the operating room: results from the National Anesthesia Clinical Outcomes Registry. March 7, 2018 Chang B, Kaye AD, Diaz JH, et al. Interventional Procedures Outside of the Operating Room: Results From the National Anesthesia Clinical Outcomes Registry. J Patient Saf. 2018;14(…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41571/psn-pdf
    October 29, 2012 - Adverse drug events caused by serious medication administration errors. October 29, 2012 Kale A, Keohane C, Maviglia SM, et al. Adverse drug events caused by serious medication administration errors. BMJ Qual Saf. 2012;21(11):933-8. doi:10.1136/bmjqs-2012-000946. https://psnet.ahrq.gov/issue/adverse-drug-events-ca…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45280/psn-pdf
    September 01, 2018 - Fighting MRSA infections in hospital care: how organizational factors matter. September 1, 2018 Salge TO, Vera A, Antons D, et al. Fighting MRSA Infections in Hospital Care: How Organizational Factors Matter. Health Serv Res. 2016;52(3):959-983. doi:10.1111/1475-6773.12521. https://psnet.ahrq.gov/issue/fighting-mr…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836995/psn-pdf
    April 27, 2022 - Multifactorial interventions to reduce duration and variability in delays to identification of serious injury after falls in hospital inpatients. April 27, 2022 Saleem J, Sarma D, Wright H, et al. Multifactorial interventions to reduce duration and variability in delays to identification of serious injury after fa…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47447/psn-pdf
    February 22, 2019 - Identifying health information technology related safety event reports from patient safety event report databases. February 22, 2019 Fong A, Adams KT, Gaunt MJ, et al. Identifying health information technology related safety event reports from patient safety event report databases. J Biomed Inform. 2018;86:135-142.…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46153/psn-pdf
    May 31, 2017 - Adverse health events related to self-medication practices among elderly: a systematic review. May 31, 2017 Locquet M, Honvo G, Rabenda V, et al. Adverse health events related to self-medication practices among elderly: a systematic review. Drugs Aging. 2017;34(5):359-365. doi:10.1007/s40266-017-0445-y. https://ps…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46814/psn-pdf
    July 25, 2018 - The scope of drug-related problems in the home care setting. July 25, 2018 Meyer-Massetti C, Meier CR, Guglielmo J. The scope of drug-related problems in the home care setting. Int J Clin Pharm. 2018;40(2):325-334. doi:10.1007/s11096-017-0581-9. https://psnet.ahrq.gov/issue/scope-drug-related-problems-home-care-se…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47397/psn-pdf
    January 09, 2019 - Using patient safety reporting systems to understand the clinical learning environment: a content analysis. January 9, 2019 Sellers MM, Berger I, Myers JS, et al. Using Patient Safety Reporting Systems to Understand the Clinical Learning Environment: A Content Analysis. J Surg Educ. 2018;75(6):e168-e177. doi:10.10…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40381/psn-pdf
    May 25, 2011 - Medication errors in the homes of children with chronic conditions. May 25, 2011 Walsh KE, Mazor KM, Stille CJ, et al. Medication errors in the homes of children with chronic conditions. Arch Dis Child. 2011;96(6):581-6. doi:10.1136/adc.2010.204479. https://psnet.ahrq.gov/issue/medication-errors-homes-children-chr…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61090/psn-pdf
    November 04, 2020 - Association of intraoperative anaesthesia handovers with patient morbidity and mortality: a systematic review and meta-analysis. November 4, 2020 Boet S, Djokhdem H, Leir SA, et al. Association of intraoperative anaesthesia handovers with patient morbidity and mortality: a systematic review and meta-analysis. Br J…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838624/psn-pdf
    October 19, 2022 - Association of rapid response teams with hospital mortality in Medicare patients. October 19, 2022 Girotra S, Jones PG, Peberdy MA, et al. Association of rapid response teams with hospital mortality in Medicare patients. Circ Cardiovasc Qual Outcomes. 2022;15(9):e008901. doi:10.1161/circoutcomes.122.008901. https…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44316/psn-pdf
    March 20, 2017 - Improving Patient Safety: The Intersection of Safety Culture, Clinician and Staff Support, and Patient Safety Organizations. March 20, 2017 Miller RG, Scott SD, Hirschinger LE. Jefferson City, MO: Center for Patient Safety; September 2015. https://psnet.ahrq.gov/issue/improving-patient-safety-intersection-safety-c…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43867/psn-pdf
    March 11, 2015 - Applying fault tree analysis to the prevention of wrong- site surgery. March 11, 2015 Abecassis ZA, McElroy LM, Patel RM, et al. Applying fault tree analysis to the prevention of wrong-site surgery. J Surg Res. 2015;193(1):88-94. doi:10.1016/j.jss.2014.08.062. https://psnet.ahrq.gov/issue/applying-fault-tree-analy…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840165/psn-pdf
    November 16, 2022 - Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. November 16, 2022 Washington, DC: Veterans Affairs Office of Inspector General; 2022. Report No. 22-00818-03. https://psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-facilities-…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73135/psn-pdf
    April 14, 2021 - Debrief it all: a tool for inclusion of Safety-II. April 14, 2021 Bentley SK, McNamara S, Meguerdichian MJ, et al. Debrief it all: a tool for inclusion of Safety-II. Adv Simul (Lond). 2021;6(1):9. doi:10.1186/s41077-021-00163-3. https://psnet.ahrq.gov/issue/debrief-it-all-tool-inclusion-safety-ii Debriefing is a c…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47670/psn-pdf
    March 20, 2019 - Targeting the fear of safety reporting on a unit level. March 20, 2019 Copeland D. Targeting the Fear of Safety Reporting on a Unit Level. J Nurs Adm. 2019;49(3):121-124. doi:10.1097/NNA.0000000000000724. https://psnet.ahrq.gov/issue/targeting-fear-safety-reporting-unit-level Blame culture in health care settings …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45308/psn-pdf
    September 28, 2016 - Measurement of patient safety: a systematic review of the reliability and validity of adverse event detection with record review. September 28, 2016 Hanskamp-Sebregts M, Zegers M, Vincent CA, et al. Measurement of patient safety: a systematic review of the reliability and validity of adverse event detection with r…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44962/psn-pdf
    March 09, 2016 - Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices. March 9, 2016 Washington, DC: United States Government Accountability Office; February 2016. Publication GAO-16- 308. https://psnet.ahrq.gov/issue/patient-safety-hospitals-face-challenges-implementing-evidence-based- practices Despi…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36528/psn-pdf
    January 20, 2010 - Creating high reliability in health care organizations. January 20, 2010 Pronovost P, Berenholtz SM, Goeschel CA, et al. Creating high reliability in health care organizations. Health Serv Res. 2006;41(4 Pt 2):1599-1617. https://psnet.ahrq.gov/issue/creating-high-reliability-health-care-organizations High-reliabil…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36333/psn-pdf
    July 10, 2008 - The care transitions intervention: results of a randomized controlled trial. July 10, 2008 Coleman EA, Parry C, Chalmers S, et al. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-8. https://psnet.ahrq.gov/issue/care-transitions-intervention-results-ra…
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