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  1. 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…

  2. 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-…

  3. 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…

  4. 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. …

  5. 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…

  6. 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…

  7. 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-…

  8. 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…

  9. 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…

  10. 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…

  11. 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…

  12. General Patient Safety Program, Center for Quality Improvement and Patient Safety | Digital Healthcare Research

    digital.ahrq.gov/program/general-patient-safety-program-center-quality-improvement-and-patient-safety
    January 01, 2023 - General Patient Safety Program, Center for Quality Improvement and Patient Safety Program Link: https://www.ahrq.gov/patient-safety/index.html Artificial Intelligence and Human Factors in Healthcare Quality & Safety Description Using a conference model…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39123/psn-pdf
    April 30, 2014 - Incorrect surgical procedures within and outside of the operating room. April 30, 2014 Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room. Arch Surg. 2009;144(11):1028-34. doi:10.1001/archsurg.2009.126. https://psnet.ahrq.gov/issue/incorrect-surgical-proced…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61042/psn-pdf
    January 01, 2022 - Patient misidentification events in the Veterans Health Administration: a comprehensive review in the context of high-reliability health care. October 21, 2020 Kulju S, Morrish W, King LA, et al. Patient misidentification events in the Veterans Health Administration: a comprehensive review in the context of high-r…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47225/psn-pdf
    November 02, 2018 - Preventable adverse drug events among inpatients: a systematic review. November 2, 2018 Gates PJ, Meyerson SA, Baysari M, et al. Preventable Adverse Drug Events Among Inpatients: A Systematic Review. Pediatrics. 2018;142(3):e20180805. doi:10.1542/peds.2018-0805. https://psnet.ahrq.gov/issue/preventable-adverse-dru…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34746/psn-pdf
    July 08, 2016 - To Err Is Human: Building a Safer Health System. July 8, 2016 Kohn KT, Corrigan JM, Donaldson MS, eds. Washington, DC: Committee on Quality Health Care in America, Institute of Medicine: National Academy Press; 1999. https://psnet.ahrq.gov/issue/err-human-building-safer-health-system One measure of the impact of t…

  17. 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…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43593/psn-pdf
    May 06, 2015 - Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project. May 6, 2015 Chicago, IL: American Hospital Association, Health Research and Educational Trust, and Joint Commission Center for Transforming Healthcare; 2014. https://psnet.ahrq.gov/issu…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42113/psn-pdf
    March 20, 2013 - Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. March 20, 2013 Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):410-416. doi:10.7326/0003-4819-158-5-201303051-00008. https:/…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38964/psn-pdf
    November 27, 2009 - Development of a measure of patient safety event learning responses. November 27, 2009 Ginsburg LR, Chuang Y-T, Norton PG, et al. Development of a measure of patient safety event learning responses. Health Serv Res. 2009;44(6):2123-47. doi:10.1111/j.1475-6773.2009.01021.x. https://psnet.ahrq.gov/issue/development-…
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