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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/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…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46651/psn-pdf
    January 17, 2018 - Piloting a patient safety and quality improvement co- curriculum. January 17, 2018 Kroker-Bode C, Whicker SA, Pline ER, et al. Piloting a patient safety and quality improvement co- curriculum. J Community Hosp Intern Med Perspect. 2017;7(6):351-357. doi:10.1080/20009666.2017.1403830. https://psnet.ahrq.gov/issue/…
  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/38831/psn-pdf
    August 05, 2009 - Rural hospital information technology implementation for safety and quality improvement: lessons learned. August 5, 2009 Tietze MF, Williams J, Galimbertti M. Rural hospital information technology implementation for safety and quality improvement: lessons learned. Comput Inform Nurs. 2009;27(4):206-14. doi:10.1097…
  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/44368/psn-pdf
    September 29, 2017 - A systematic review of the effect of distraction on surgeon performance: directions for operating room policy and surgical training. September 29, 2017 Mentis HM, Chellali A, Manser K, et al. A systematic review of the effect of distraction on surgeon performance: directions for operating room policy and surgical …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45571/psn-pdf
    January 18, 2017 - How communication among members of the health care team affects maternal morbidity and mortality. January 18, 2017 Brennan RA, Keohane CA. How Communication Among Members of the Health Care Team Affects Maternal Morbidity and Mortality. J Obstet Gynecol Neonatal Nurs. 2016;45(6):878-884. doi:10.1016/j.jogn.2016.03…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44156/psn-pdf
    November 10, 2015 - Exploring the role of communications in quality improvement: a case study of the 1000 Lives Campaign in NHS Wales. November 10, 2015 Cooper A, Gray J, Willson A, et al. Exploring the role of communications in quality improvement: A case study of the 1000 Lives Campaign in NHS Wales. J Commun Healthc. 2015;8(1):76-…
  14. 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):…
  15. 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…
  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/866395/psn-pdf
    July 23, 2024 - Creating an environment where a culture of safety is incorporated into daily practice is the ultimate
  18. psnet.ahrq.gov/primer/national-patient-safety-goals
    January 16, 2025 - implementation of NPSGs is enhanced through proactive, coordinated, and systems-level approaches that are incorporated
  19. 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…
  20. psnet.ahrq.gov/issue/vha-national-patient-safety-improvement-handbook
    April 12, 2019 - Organizational Policy/Guidelines VHA National Patient Safety Improvement Handbook. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL January 17, 2012 A handbook developed by the …

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