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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50655/psn-pdf
    January 01, 2020 - Reflections on implementing a hospital-wide provider- based electronic inpatient mortality review system: lessons learnt. November 13, 2019 Mendu ML, Lu Y, Petersen A, et al. Reflections on implementing a hospital-wide provider-based electronic inpatient mortality review system: lessons learnt. BMJ Qual Saf. 2020;…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73215/psn-pdf
    May 05, 2021 - To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. May 5, 2021 Isherwood P, Waterson P. To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. J Patient Saf Risk Manag. 2021;26(2):64-73. doi:10.1177/2516043521990…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44876/psn-pdf
    February 10, 2016 - The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, System Failures and Lack of Mindfulness. February 10, 2016 Anderson-Fletcher E, Vera D, Abbott J. Houston, TX: Hobbs Center for Public Policy, University of Houston; 2015. https://psnet.ahrq.gov/issue/texas-health-presbyterian-h…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849325/psn-pdf
    January 01, 2024 - Medication safety event reporting: factors that contribute to safety events during times of organizational stress. May 24, 2023 Cohen TN, Berdahl CT, Coleman BL, et al. Medication safety event reporting: factors that contribute to safety events during times of organizational stress. J Nurs Care Qual. 2024;39(1):51-…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45487/psn-pdf
    July 21, 2020 - Annotated bibliography: an update to: "Understanding ambulatory care practices in the context of patient safety and quality improvement." July 21, 2020 Kumar PR, Nash DB. Annotated Bibliography: An Update to “Understanding Ambulatory Care Practices in the Context of Patient Safety and Quality Improvement”. Am J Me…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35516/psn-pdf
    February 03, 2011 - Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. February 3, 2011 Belda J, Aguilera L, de la Asunción JG, et al. Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. JAMA. 2005;294(16):2035-42. https://p…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/764394/psn-pdf
    March 02, 2022 - Assessing resident and attending error and adverse events in the emergency department. March 2, 2022 Adler JL, Gurley K, Rosen CL, et al. Assessing resident and attending error and adverse events in the emergency department. Am J Emerg Med. 2022;54:228-231. doi:10.1016/j.ajem.2022.01.015. https://psnet.ahrq.gov/is…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74080/psn-pdf
    January 01, 2022 - The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center. November 17, 2021 Krishnan S, Wheeler KK, Pimentel MP, et al. The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center.…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74152/psn-pdf
    December 08, 2021 - Adverse events and their contributors among older adults during skilled nursing stays for rehabilitation: a scoping review. December 8, 2021 Okpalauwaekwe U, Tzeng H-M. Adverse events and their contributors among older adults during skilled nursing stays for rehabilitation: a scoping review. Patient Relat Outcome …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47077/psn-pdf
    May 23, 2018 - World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. May 23, 2018 Gelb AW, Morriss WW, Johnson W, et al. World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards fo…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45613/psn-pdf
    September 01, 2018 - Patients as partners in learning from unexpected events. September 1, 2018 Etchegaray J, Ottosen M, Aigbe A, et al. Patients as Partners in Learning from Unexpected Events. Health Serv Res. 2016;51 Suppl 3:2600-2614. doi:10.1111/1475-6773.12593. https://psnet.ahrq.gov/issue/patients-partners-learning-unexpected-eve…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837681/psn-pdf
    September 11, 2023 - Compendium of Strategies to Prevent HAIs in Acute Care Hospitals 2022. September 11, 2023 Infect Control Hosp Epidemiol. 2022-2023. https://psnet.ahrq.gov/issue/compendium-strategies-prevent-hais-acute-care-hospitals-2022 Health care–associated infections (HAIs) affect patients both during and after hospitalizatio…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61072/psn-pdf
    October 28, 2020 - Reducing nosocomial transmission of COVID-19: implementation of a COVID-19 triage system. October 28, 2020 Wake RM, Morgan M, Choi J, et al. Reducing nosocomial transmission of COVID-19: implementation of a COVID-19 triage system. Clin Med (Lond). 2020;20(5):e141-e145. doi:10.7861/clinmed.2020-0411. https://psnet.…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867382/psn-pdf
    December 18, 2024 - Pharmacists’ perceptions of error reporting systems. December 18, 2024 Hartt CM, Weigand H, MacDonald AJ, et al. Pharmacists’ perceptions of error reporting systems. J Patient Saf Risk Manag. 2024;29(6):268-273. doi:10.1177/25160435241288287. https://psnet.ahrq.gov/issue/pharmacists-perceptions-error-reporting-syst…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41043/psn-pdf
    May 24, 2012 - Toward improving patient safety through voluntary peer- to-peer assessment. May 24, 2012 Hudson DW, Holzmueller CG, Pronovost P, et al. Toward improving patient safety through voluntary peer- to-peer assessment. Am J Med Qual. 2012;27(3):201-9. doi:10.1177/1062860611421981. https://psnet.ahrq.gov/issue/toward-impr…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/856588/psn-pdf
    November 29, 2023 - It depends who you ask: divergences in staff and external stakeholder narratives about the causes of a healthcare failure. November 29, 2023 Hald EJ, Gillespie A, Reader TW. It depends who you ask: divergences in staff and external stakeholder narratives about the causes of a healthcare failure. J Contingencies Cr…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50745/psn-pdf
    December 18, 2019 - Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis. December 18, 2019 Appelbaum N, Clarke J, Feather C, et al. Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis. BMJ Open. 2019;9(1…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60293/psn-pdf
    May 06, 2020 - Blueprint for restructuring a department of surgery in concert with the health care system during a pandemic: the University of Wisconsin Experience. May 6, 2020 Zarzaur BL, Stahl CC, Greenberg JA, et al. Blueprint for restructuring a department of surgery in concert with the health care system during a pandemic: …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46509/psn-pdf
    May 17, 2018 - Impact of out-of-hours admission on patient mortality: longitudinal analysis in a tertiary acute hospital. May 17, 2018 Han L, Sutton M, Clough S, et al. Impact of out-of-hours admission on patient mortality: longitudinal analysis in a tertiary acute hospital. BMJ Qual Saf. 2018;27(6):445-454. doi:10.1136/bmjqs-201…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41359/psn-pdf
    November 21, 2016 - The relationship between organizational culture and family satisfaction in critical care. November 21, 2016 Dodek P, Wong H, Heyland DK, et al. The relationship between organizational culture and family satisfaction in critical care. Crit Care Med. 2012;40(5):1506-12. doi:10.1097/CCM.0b013e318241e368. https://psne…
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