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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34775/psn-pdf
    February 07, 2019 - Escape Fire: Lessons for the Future of Health Care. February 7, 2019 Berwick DM. Washington DC: Commonwealth Fund; 2002. https://psnet.ahrq.gov/issue/escape-fire-lessons-future-health-care This report represents an edited version of Donald Berwick’s Plenary Address presented at the Institute for Healthcare Improve…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50406/psn-pdf
    October 02, 2019 - The co-design, implementation and evaluation of a serious board game 'PlayDecide patient safety' to educate junior doctors about patient safety and the importance of reporting safety concerns October 2, 2019 Ward M, Shé ÉN, De Brún A, et al. The co-design, implementation and evaluation of a serious board game 'Pl…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74203/psn-pdf
    December 22, 2021 - Surgical safety checklist audits may be misleading! Improving the implementation and adherence of the surgical safety checklist: a quality improvement project. December 22, 2021 Brown B, Bermingham S, Vermeulen M, et al. Surgical safety checklist audits may be misleading! Improving the implementation and adherence…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43735/psn-pdf
    January 20, 2015 - Patient safety is not elective: a debate at the NPSF Patient Safety Congress. January 20, 2015 McTiernan P, Wachter R, Meyer GS, et al. Patient safety is not elective: a debate at the NPSF Patient Safety Congress. BMJ Qual Saf. 2015;24(2):162-6. doi:10.1136/bmjqs-2014-003429. https://psnet.ahrq.gov/issue/patient-s…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44061/psn-pdf
    November 16, 2015 - Quality improvement and patient safety organizations in anesthesiology. November 16, 2015 Dutton RP. Quality improvement and patient safety organizations in anesthesiology. AMA J Ethics. 2015;17(3):248-52. doi:10.1001/journalofethics.2015.17.3.pfor1-1503. https://psnet.ahrq.gov/issue/quality-improvement-and-patien…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47232/psn-pdf
    November 14, 2018 - Managing alarm systems for quality and safety in the hospital setting. November 14, 2018 Bach TA, Berglund L-M, Turk E. Managing alarm systems for quality and safety in the hospital setting. BMJ Open Qual. 2018;7(3):e000202. doi:10.1136/bmjoq-2017-000202. https://psnet.ahrq.gov/issue/managing-alarm-systems-quality…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39102/psn-pdf
    January 04, 2010 - Quality and safety on an acute surgical ward: an exploratory cohort study of process and outcome. January 4, 2010 Kreckler S, Catchpole K, New SJ, et al. Quality and safety on an acute surgical ward: an exploratory cohort study of process and outcome. Ann Surg. 2009;250(6):1035-40. doi:10.1097/SLA.0b013e3181bd54c2.…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43058/psn-pdf
    March 26, 2014 - A strategic approach to quality improvement and patient safety education and resident integration in a general surgery residency. March 26, 2014 O'Heron CT, Jarman BT. A strategic approach to quality improvement and patient safety education and resident integration in a general surgery residency. J Surg Educ. 2014…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867335/psn-pdf
    December 11, 2024 - Comparing safety, performance and user perceptions of a patient-specific indication-based prescribing tool with current practice: a mixed methods randomised user testing study. December 11, 2024 Feather C, Clarke J, Appelbaum N, et al. Comparing safety, performance and user perceptions of a patient- specific indi…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47158/psn-pdf
    August 15, 2018 - A standardized handoff simulation promotes recovery from auditory distractions in resident physicians. August 15, 2018 Matern LH, Farnan JM, Hirsch KW, et al. A Standardized Handoff Simulation Promotes Recovery From Auditory Distractions in Resident Physicians. Simul Healthc. 2018;13(4):233-238. doi:10.1097/SIH.00…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46626/psn-pdf
    December 22, 2018 - What happened to my patient? An educational intervention to facilitate postdischarge patient follow-up. December 22, 2018 Narayana S, Rajkomar A, Harrison JD, et al. What Happened to My Patient? An Educational Intervention to Facilitate Postdischarge Patient Follow-Up. J Grad Med Educ. 2017;9(5):627-633. doi:10.430…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43021/psn-pdf
    November 04, 2014 - Patient safety culture transformation in a children's hospital: an interprofessional approach. November 4, 2014 Nagelkerk J, Peterson T, Pawl BL, et al. Patient safety culture transformation in a children's hospital: an interprofessional approach. J Interprof Care. 2014;28(4):358-64. doi:10.3109/13561820.2014.88593…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46364/psn-pdf
    September 24, 2017 - Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors. September 24, 2017 Seoane-Vazquez E, Rodriguez-Monguio R, Alqahtani S, et al. Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors. Expert Opin Drug Saf. 2017;16(10):…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43210/psn-pdf
    May 28, 2014 - Improving cancer patient care with combined medication error reviews and morbidity and mortality conferences. May 28, 2014 Ranchon F, You B, Salles G, et al. Improving Cancer Patient Care with Combined Medication Error Reviews and Morbidity and Mortality Conferences. Chemotherapy (Los Angel). 2014;59(5). doi:10.11…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44869/psn-pdf
    November 18, 2016 - Fake and expired medications in simulation-based education: an underappreciated risk to patient safety. November 18, 2016 Torrie J, Cumin D, Sheridan J, et al. Fake and expired medications in simulation-based education: an underappreciated risk to patient safety. BMJ Qual Saf. 2016;25(12):917-920. doi:10.1136/bmjqs…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47106/psn-pdf
    August 15, 2018 - Imitating incidents: how simulation can improve safety investigation and learning from adverse events. August 15, 2018 Macrae C. Imitating Incidents: How Simulation Can Improve Safety Investigation and Learning From Adverse Events. Simul Healthc. 2018;13(4):227-232. doi:10.1097/SIH.0000000000000315. https://psnet.…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73140/psn-pdf
    April 14, 2021 - Association between primary care physician diagnostic knowledge and death, hospitalisation and emergency department visits following an outpatient visit at risk for diagnostic error: a retrospective cohort study using medicare claims. April 14, 2021 Gray BM, Vandergrift JL, McCoy RG, et al. Association between pr…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44459/psn-pdf
    October 06, 2016 - Examining the Relationship Between Health IT and Ambulatory Care Workflow Redesign. October 6, 2016 Zheng K, Ciemins EL, Lanham HJ, et al. Rockville, MD: Agency for Healthcare Research and Quality; July 2015. AHRQ Publication No. 15-0058-EF. https://psnet.ahrq.gov/issue/examining-relationship-between-health-it-and…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34649/psn-pdf
    June 11, 2014 - On error management: lessons from aviation. June 11, 2014 Helmreich RL. On error management: lessons from aviation. BMJ . 2000;320(7237):781-785. https://psnet.ahrq.gov/issue/error-management-lessons-aviation In this perspective, the author draws on analogies from aviation to frame the issues of patient safety and …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38400/psn-pdf
    February 11, 2009 - The impact of clinically undiagnosed injuries on survival estimates. February 11, 2009 Gedeborg R, Thiblin I, Byberg L, et al. The impact of clinically undiagnosed injuries on survival estimates. Crit Care Med. 2009;37(2). doi:10.1097/ccm.0b013e318194b164. https://psnet.ahrq.gov/issue/impact-clinically-undiagnosed…

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