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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866081/psn-pdf
    June 05, 2024 - "The patient is awake and we need to stay calm": reconsidering indirect communication in the face of medical error and professionalism lapses. June 5, 2024 Taylor T, Columbus L, Banner H, et al. “The patient is awake and we need to stay calm”: reconsidering indirect communication in the face of medical error and p…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42758/psn-pdf
    October 17, 2016 - Suffering in silence: a qualitative study of second victims of adverse events. October 17, 2016 Ullström S, Sachs MA, Hansson J, et al. Suffering in silence: a qualitative study of second victims of adverse events. BMJ Qual Saf. 2014;23(4):325-331. doi:10.1136/bmjqs-2013-002035. https://psnet.ahrq.gov/issue/suffer…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46197/psn-pdf
    September 24, 2017 - Implementation and evaluation of a prototype consumer reporting system for patient safety events. September 24, 2017 Weingart SN, Weissman JS, Zimmer KP, et al. Implementation and evaluation of a prototype consumer reporting system for patient safety events. Int J Qual Health Care. 2017;29(4):521-526. doi:10.1093/…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845298/psn-pdf
    March 01, 2023 - National statutory reporting: not even ticking the boxes? The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020. March 1, 2023 Brummell Z, Braun D, Hussein Z, et al. National statutory reporting: not even ticking the boxes? The quality of ‘Learning from Deaths’ rep…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40993/psn-pdf
    December 14, 2011 - Anticoagulation-associated adverse drug events. December 14, 2011 Piazza G, Nguyen TN, Cios D, et al. Anticoagulation-associated Adverse Drug Events. Am J Med. 2011;124(12). doi:10.1016/j.amjmed.2011.06.009. https://psnet.ahrq.gov/issue/anticoagulation-associated-adverse-drug-events Warfarin and other anticoagulan…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844040/psn-pdf
    February 08, 2023 - A customized triggers program: a children's hospital's experience in improving trigger usability. February 8, 2023 Reinhart RM, Safari-Ferra P, Badh R, et al. A customized triggers program: a children's hospital's experience in improving trigger usability. Pediatrics. 2023;151(2):e2022056452. doi:10.1542/peds.2022-…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50370/psn-pdf
    January 01, 2020 - Debunking the myth that the majority of medical errors are attributed to communication. September 25, 2019 Clapper TC, Ching K. Debunking the myth that the majority of medical errors are attributed to communication. Med Educ. 2020;54(1):74-81. doi:10.1111/medu.13821. https://psnet.ahrq.gov/issue/debunking-myth-maj…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851348/psn-pdf
    July 12, 2023 - Widespread misinterpretation of advance directives and Portable Orders for Life-Sustaining Treatments threatens patient safety and causes undertreatment and overtreatment. July 12, 2023 Mirarchi FL, Pope TM. Widespread misinterpretation of advance directives and Portable Orders for Life- Sustaining Treatments thr…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44960/psn-pdf
    February 14, 2017 - Readmissions, observation, and the Hospital Readmissions Reduction Program. February 14, 2017 Zuckerman RB, Sheingold SH, Orav J, et al. Readmissions, Observation, and the Hospital Readmissions Reduction Program. N Engl J Med. 2016;374(16):1543-51. doi:10.1056/NEJMsa1513024. https://psnet.ahrq.gov/issue/readmissio…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42474/psn-pdf
    September 19, 2015 - A new, evidence-based estimate of patient harms associated with hospital care. September 19, 2015 James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9(3):122-128. doi:10.1097/PTS.0b013e3182948a69. https://psnet.ahrq.gov/issue/new-evidence-based-estimate-pat…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41572/psn-pdf
    October 29, 2012 - Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. October 29, 2012 Winters BD, Custer J, Galvagno SM, et al. Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. BMJ Qual Saf. 2012;21(11):894-902. doi:10.1136/bmjqs-2012-000803. https://psnet.ahrq…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848815/psn-pdf
    May 10, 2023 - Identifying adverse events in patients hospitalized in isolation or quarantine due to COVID-19. May 10, 2023 de Arriba Fernández A, Sánchez Medina R, Dorta Hung ME, et al. Identifying adverse events in patients hospitalized in isolation or quarantine due to COVID-19. J Patient Saf. 2023;19(4):249-250. doi:10.1097/…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60642/psn-pdf
    July 01, 2020 - Opioid prescribing after childbirth and risk for serious opioid-related events: a cohort study. July 1, 2020 Osmundson SS, Min JY, Wiese AD, et al. Opioid Prescribing After Childbirth and Risk for Serious Opioid- Related Events: A Cohort Study. Ann Intern Med. 2020;173(5):412-414. doi:10.7326/m19-3805. https://psn…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40539/psn-pdf
    June 22, 2011 - Medication administration errors in assisted living: scope, characteristics, and the importance of staff training. June 22, 2011 Zimmerman S, Love K, Sloane PD, et al. Medication administration errors in assisted living: scope, characteristics, and the importance of staff training. J Am Geriatr Soc. 2011;59(6):1060…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36174/psn-pdf
    September 29, 2010 - Performance of International Classification of Diseases, 9th Revision, Clinical Modification codes as an adverse drug event surveillance system. September 29, 2010 Hougland P, Xu W, Pickard S, et al. Performance of International Classification Of Diseases, 9th Revision, Clinical Modification codes as an adverse dr…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44699/psn-pdf
    December 16, 2015 - Suicide attempts after emergency room visits: the effect of patient safety goals. December 16, 2015 Robst J. Suicide Attempts After Emergency Room Visits: The Effect of Patient Safety Goals. Psych Q. 2015;86(4):497-504. doi:10.1007/s11126-015-9345-7. https://psnet.ahrq.gov/issue/suicide-attempts-after-emergency-ro…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836967/psn-pdf
    April 20, 2022 - Hospital acquired infections in surgical patients: impact of COVID-19-related infection prevention measures. April 20, 2022 Tham N, Fazio T, Johnson D, et al. Hospital acquired infections in surgical patients: impact of COVID-19- related infection prevention measures. World J Surg. 2022;46:1249-1258. doi:10.1007/s0…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45585/psn-pdf
    June 29, 2017 - Impact of Medicare's nonpayment program on hospital- acquired conditions. June 29, 2017 Thirukumaran CP, Glance LG, Temkin-Greener H, et al. Impact of Medicare's Nonpayment Program on Hospital-acquired Conditions. Med Care. 2017;55(5):447-455. doi:10.1097/MLR.0000000000000680. https://psnet.ahrq.gov/issue/impact-m…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44626/psn-pdf
    November 04, 2015 - "SWARMing" to improve patient care: a novel approach to root cause analysis. November 4, 2015 Li J, Boulanger B, Norton J, et al. "SWARMing" to Improve Patient Care: A Novel Approach to Root Cause Analysis. Jt Comm J Qual Patient Saf. 2015;41(11):494-501. https://psnet.ahrq.gov/issue/swarming-improve-patient-care-…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/764402/psn-pdf
    March 02, 2022 - A systematic review of methods for medical record analysis to detect adverse events in hospitalized patients. March 2, 2022 Klein DO, Rennenberg RJMW, Koopmans RP, et al. A systematic review of methods for medical record analysis to detect adverse events in hospitalized patients. J Patient Saf. 2021;17(8):e1234-e12…
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