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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36697/psn-pdf
    February 03, 2011 - Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. February 3, 2011 Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care phys…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37942/psn-pdf
    May 04, 2014 - Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk. May 4, 2014 Berkenstadt H, Haviv Y, Tuval A, et al. Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managi…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36577/psn-pdf
    January 12, 2011 - Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. January 12, 2011 Nielsen PE, Goldman MB, Mann S, et al. Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. Obstet Gyneco…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47153/psn-pdf
    October 12, 2018 - Clinicians' perceptions of medication errors with opioids in cancer and palliative care services: a priority setting report. October 12, 2018 Heneka N, Shaw T, Azzi C, et al. Clinicians' perceptions of medication errors with opioids in cancer and palliative care services: a priority setting report. Support Care Ca…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46283/psn-pdf
    April 24, 2018 - Decreasing prescribing errors during pediatric emergencies: a randomized simulation trial. April 24, 2018 Larose G, Levy A, Bailey B, et al. Decreasing Prescribing Errors During Pediatric Emergencies: A Randomized Simulation Trial. Pediatrics. 2017;139(3). doi:10.1542/peds.2016-3200. https://psnet.ahrq.gov/issue/d…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837198/psn-pdf
    May 25, 2022 - The association of acute COVID-19 infection with Patient Safety Indicator-12 events in a multisite healthcare system. May 25, 2022 Bhakta S, Pollock BD, Erben YM, et al. The association of acute COVID?19 infection with Patient Safety Indicator?12 events in a multisite healthcare system. J Hosp Med. 2022;17(5):350-…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44497/psn-pdf
    September 09, 2015 - VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events. September 9, 2015 Washington, DC: United States Government Accountability Office; July 29, 2015. Publication GAO-15-643. https://psnet.ahrq.gov/issue/va-health-care-actions-needed-assess-decrease-root-cause-analyses- advers…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39402/psn-pdf
    August 08, 2010 - The quest to eliminate intrathecal vincristine errors: a 40- year journey. August 8, 2010 Noble DJ, Donaldson LJ. The quest to eliminate intrathecal vincristine errors: a 40-year journey. Qual Saf Health Care. 2010;19(4):323-326. doi:10.1136/qshc.2008.030874. https://psnet.ahrq.gov/issue/quest-eliminate-intratheca…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42721/psn-pdf
    December 12, 2014 - Infusional chemotherapy and medication errors in a tertiary care pediatric cancer unit in a resource-limited setting. December 12, 2014 Dhamija M, Kapoor G, Juneja A. Infusional chemotherapy and medication errors in a tertiary care pediatric cancer unit in a resource-limited setting. J Pediatr Hematol Oncol. 2014;…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42266/psn-pdf
    May 15, 2013 - Medication errors in the home: a multisite study of children with cancer. May 15, 2013 Walsh KE, Roblin DW, Weingart SN, et al. Medication errors in the home: a multisite study of children with cancer. Pediatrics. 2013;131(5):e1405-14. doi:10.1542/peds.2012-2434. https://psnet.ahrq.gov/issue/medication-errors-home…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44558/psn-pdf
    April 25, 2016 - Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine. April 25, 2016 Okafor N, Payne VL, Chathampally Y, et al. Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine. Emerg Med J. 2016;33(4):245-252. doi:10.1136/emermed-2014- 204604. …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41404/psn-pdf
    December 31, 2014 - Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial. December 31, 2014 Schnipper JL, Gandhi TK, Wald JS, et al. Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial. J Am Med Inform Assoc. 2012;19(5):728-34. …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38692/psn-pdf
    March 04, 2015 - Errare humanum est: frequency of laterality errors in radiology reports. March 4, 2015 Sangwaiya MJ, Saini S, Blake MA, et al. Errare humanum est: frequency of laterality errors in radiology reports. AJR Am J Roentgenol. 2009;192(5):W239-44. doi:10.2214/AJR.08.1778. https://psnet.ahrq.gov/issue/errare-humanum-est-…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47529/psn-pdf
    January 21, 2019 - Community-acquired and hospital-acquired medication harm among older inpatients and impact of a state-wide medication management intervention. January 21, 2019 Pellegrin K, Lozano A, Miyamura J, et al. Community-acquired and hospital-acquired medication harm among older inpatients and impact of a state-wide medica…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41925/psn-pdf
    November 26, 2014 - Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge. November 26, 2014 Ziaeian B, Araujo KLB, Van Ness PH, et al. Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge. J Gen Intern Med. 2012;2…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44248/psn-pdf
    May 26, 2016 - Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. May 26, 2016 Hempel S, Maggard-Gibbons M, Nguyen DK, et al. Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires : A Systematic Review of Surgical Never Events. JAMA Surg. 2015;150(8):796-805. …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37546/psn-pdf
    June 14, 2011 - Effective interventions and implementation strategies to reduce adverse drug events in the Veterans Affairs (VA) system. June 14, 2011 Mills PD, Neily J, Kinney LM, et al. Effective interventions and implementation strategies to reduce adverse drug events in the Veterans Affairs (VA) system. Qual Saf Health Care. …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34688/psn-pdf
    March 28, 2005 - Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. March 28, 2005 Classen DC, Pestotnik SL, Evans RS, et al. Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1997;277(4):301-6. https://psne…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40925/psn-pdf
    December 07, 2011 - Improving the discharge process by embedding a discharge facilitator in a resident team. December 7, 2011 Finn KM, Heffner R, Chang Y, et al. Improving the discharge process by embedding a discharge facilitator in a resident team. J Hosp Med. 2011;6(9):494-500. doi:10.1002/jhm.924. https://psnet.ahrq.gov/issue/imp…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61061/psn-pdf
    October 28, 2020 - Safer prescribing for hospitalized older adults with an electronic health records?based prescribing context. October 28, 2020 Drago K, Sharpe J, De Lima B, et al. Safer prescribing for hospitalized older adults with an electronic health records?based prescribing context. J Am Geriatrics Soc. 2020;68(9):2123-2127. d…
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