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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41676/psn-pdf
    September 24, 2016 - Taking a detour: positive and negative effects of supervisors' interruptions during admission case review discussions. September 24, 2016 Goldszmidt M, Aziz N, Lingard LA. Taking a detour: positive and negative effects of supervisors' interruptions during admission case review discussions. Acad Med. 2012;87(10):13…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38574/psn-pdf
    November 21, 2016 - Family-identified barriers to medication reconciliation. November 21, 2016 Riley-Lawless K. Family-identified barriers to medication reconciliation. J Spec Pediatr Nurs. 2009;14(2):94-101. doi:10.1111/j.1744-6155.2009.00182.x. https://psnet.ahrq.gov/issue/family-identified-barriers-medication-reconciliation Medica…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863224/psn-pdf
    February 28, 2024 - Special Section: IEA Health Care 2021. February 28, 2024 Hum Factors. 2024;66(3):633-769. https://psnet.ahrq.gov/issue/special-section-iea-health-care-2021 The ergonomics community has an established interest in medical error reduction. The 2021 International Ergonomics Association conference examined applications…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35302/psn-pdf
    July 14, 2009 - Technology induced error and usability: the relationship between usability problems and prescription errors when using a handheld application. July 14, 2009 Kushniruk AW, Triola MM, Borycki EM, et al. Technology induced error and usability: The relationship between usability problems and prescription errors when u…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45006/psn-pdf
    April 06, 2016 - Quality and Patient Safety. April 6, 2016 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/quality-and-patient-safety The Agency for Healthcare Research and Quality has provided access to patient safety research, information, and tools for nearly two decades. This website offers a wide rang…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60024/psn-pdf
    March 11, 2020 - Artificial intelligence and surgical decision-making. March 11, 2020 Loftus TJ, Tighe PJ, Filiberto AC, et al. Artificial intelligence and surgical decision-making. JAMA Surg. 2019;155(2):148-158. doi:10.1001/jamasurg.2019.4917. https://psnet.ahrq.gov/issue/artificial-intelligence-and-surgical-decision-making Arti…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867019/psn-pdf
    October 23, 2024 - Reports on Hospital and ASC Performance. October 23, 2024 Reports On Hospital And Asc Performance. Washington DC: The Leapfrog Group; September 2024. https://psnet.ahrq.gov/issue/reports-hospital-and-asc-performance Data collection and transparency are known to motivate change and drive improvement efforts. This se…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43009/psn-pdf
    January 07, 2015 - Improving the Emergency Department Discharge Process. January 7, 2015 Boonyasai RT, Ijagbemi OM, Pham JC, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. 14(15)-0067-EF. https://psnet.ahrq.gov/issue/improving-emergency-department-discharge-process This report a…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42768/psn-pdf
    November 27, 2013 - Findings and Lessons From the Improving Management of Individuals With Complex Health Care Needs Through Health IT Grant Initiative. November 27, 2013 Rockville, MD: Agency for Healthcare Research and Quality; September 2013. AHRQ Publication No. 13- 0058-EF.   https://psnet.ahrq.gov/issue/findings-and-lesso…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41222/psn-pdf
    May 01, 2016 - Reducing Unnecessary Hospital Readmissions: The Role of the Patient Safety Organization (PSO). May 1, 2016 Agency for Healthcare Quality and Research. https://psnet.ahrq.gov/issue/reducing-unnecessary-hospital-readmissions-role-patient-safety-organization- pso Patient safety organizations (PSO) present a unique o…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43525/psn-pdf
    July 16, 2015 - Clinical handovers between prehospital and hospital staff: literature review. July 16, 2015 Wood K, Crouch R, Rowland E, et al. Clinical handovers between prehospital and hospital staff: literature review. Emerg Med J. 2015;32(7):577-581. doi:10.1136/emermed-2013-203165. https://psnet.ahrq.gov/issue/clinical-hando…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50534/psn-pdf
    October 16, 2019 - Strategies to reduce diagnostic errors: a systematic review October 16, 2019 Abimanyi-Ochom J, Mudiyanselage SB, Catchpool M, et al. Strategies to reduce diagnostic errors: a systematic review. BMC Med Inform Decis Mak. 2019;19(1):174. doi:10.1186/s12911-019-0901-1. https://psnet.ahrq.gov/issue/strategies-reduce-d…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34036/psn-pdf
    March 28, 2005 - National Center for Patient Safety Falls Toolkit 2004. March 28, 2005 Department of Veterans Affairs (VA) National Center for Patient Safety https://psnet.ahrq.gov/issue/national-center-patient-safety-falls-toolkit-2004 The National Center for Patient Safety created the Falls Toolkit to assist VA facilities in impl…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43391/psn-pdf
    July 30, 2014 - Special Issue on Patient Safety. July 30, 2014 West J Nurs Res. 2014;36(7):851-946. https://psnet.ahrq.gov/issue/special-issue-patient-safety-0 Articles in this special issue discuss errors of omission in nursing, the importance of situational awareness during medication administration, how complexity of health ca…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39486/psn-pdf
    May 05, 2010 - Understanding handling of drug safety alerts: a simulation study. May 5, 2010 van der Sijs H, van Gelder T, Vulto A, et al. Understanding handling of drug safety alerts: a simulation study. Int J Med Inform. 2010;79(5). doi:10.1016/j.ijmedinf.2010.01.008. https://psnet.ahrq.gov/issue/understanding-handling-drug-sa…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35913/psn-pdf
    February 16, 2011 - Improving oversight of the graduate medical education enterprise: one institution's strategies and tools. February 16, 2011 Afrin LB, Arana GW, Medio FJ, et al. Improving Oversight of the Graduate Medical Education Enterprise: One Institution???s Strategies and Tools. Academic Medicine. 2006;81(5). doi:10.1097/01.…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35720/psn-pdf
    April 14, 2011 - A survey of factors affecting clinician acceptance of clinical decision support. April 14, 2011 Sittig DF, Krall MA, Dykstra RH, et al. A survey of factors affecting clinician acceptance of clinical decision support. BMC Med Inform Decis Mak. 2006;6(1). doi:10.1186/1472-6947-6-6. https://psnet.ahrq.gov/issue/surve…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44977/psn-pdf
    March 01, 2020 - Choosing a Patient Safety Organization March 1, 2020 Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0030. https://psnet.ahrq.gov/issue/choosing-patient-safety-organization Patient safety organizations (PSOs) collect and analyze protected incident data from across the …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44182/psn-pdf
    November 03, 2015 - FDA cautions about dose confusion and medication errors for antibacterial drug Zerbaxa (ceftolozane and tazobactam). November 3, 2015 Food and Drug Administration; FDA. https://psnet.ahrq.gov/issue/fda-cautions-about-dose-confusion-and-medication-errors-antibacterial-drug- zerbaxa Dosing information on drug labe…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46177/psn-pdf
    March 09, 2018 - Diagnosis: Interpreting the Shadows. March 9, 2018 Croskerry P, Cosby KS, Graber ML, Singh H. Boca Raton, FL: CRC Press; 2017. ISBN: 9781409432333. https://psnet.ahrq.gov/issue/diagnosis-interpreting-shadows Efforts to enhance the reliability of the diagnostic process must take various elements into consideration. …

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