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5301. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47114/psn-pdf
      October 13, 2018 - Focused ethnography of diagnosis in academic medical centers. October 13, 2018 Chopra V, Harrod M, Winter S, et al. Focused Ethnography of Diagnosis in Academic Medical Centers. J Hosp Med. 2018;13(10):668-672. doi:10.12788/jhm.2966. https://psnet.ahrq.gov/issue/focused-ethnography-diagnosis-academic-medical-cente…

5302. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/847735/psn-pdf
      May 30, 2023 - SOPS Ambulatory Surgery Center Survey: What You Need to Know. May 30, 2023 Agency for Healthcare Policy and Research: April 27, 2023. https://psnet.ahrq.gov/issue/sops-ambulatory-surgery-center-survey-what-you-need-know Ambulatory surgery centers (ASC) experience a variety of error types that can be exacerbated by…

5303. Safety in Pediatric Dental Care | PSNet
      psnet.ahrq.gov/training-catalog/safety-pediatric-dental-care
      August 10, 2025 - Safety in Pediatric Dental Care Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Organization: Organization American Academy of Pediatric Dentistry Event Description: Th…

5304. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836762/psn-pdf
      March 16, 2022 - Physician liability in the age of data reliance and errors. March 16, 2022 Montesantos L. Ann Health Law Life Sci. 2022;31(Spring):179-215. https://psnet.ahrq.gov/issue/physician-liability-age-data-reliance-and-errors Health information technologies (HIT) and advanced learning systems, if poorly designed, used, ma…

5305. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45367/psn-pdf
      September 28, 2016 - How PSOs Help Health Care Organizations Improve Patient Safety Culture. September 28, 2016 Rockville, MD: Agency for Healthcare Research and Quality; April 2016. AHRQ Pub. No. 16-0026-EF. https://psnet.ahrq.gov/issue/how-psos-help-health-care-organizations-improve-patient-safety-culture Patient safety organization…

5306. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47847/psn-pdf
      July 10, 2024 - CHPSO Annual Reports. July 10, 2024 California Hospital Patient Safety Organization: Sacramento, CA; 2024. https://psnet.ahrq.gov/issue/chpso-2019-annual-report Patient Safety Organizations (PSOs) capture and analyze local data to inform learning among their 490 members. This report highlights 2023 trends, activit…

5307. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44159/psn-pdf
      July 08, 2016 - Vital Signs: Core Metrics for Health and Health Care Progress. July 8, 2016 Blumenthal D, Malphrus E, McGinnis JM, eds. Committee on Core Metrics for Better Health at Lower Cost, Institute of Medicine. Washington, DC: National Academies Press; 2015. ISBN: 9780309324939. https://psnet.ahrq.gov/issue/vital-signs-cor…

5308. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60672/psn-pdf
      July 08, 2020 - The Care We Need July 8, 2020 Washington DC: National Quality Forum; 2020. https://psnet.ahrq.gov/issue/care-we-need This report builds on the legacy of To Err is Human and Crossing the Quality Chasm to outline an approach to improve the US health care system. Five strategic objectives are provided--one of which f…

5309. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34647/psn-pdf
      June 25, 2014 - Complexity science: the challenge of complexity in health care. June 25, 2014 Plsek PE, Greenhalgh T. Complexity science: The challenge of complexity in health care. BMJ. 2001;323(7313):625-628. https://psnet.ahrq.gov/issue/complexity-science-challenge-complexity-health-care This article explores the science of h…

5310. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34708/psn-pdf
      February 18, 2011 - Understanding and responding to adverse events. February 18, 2011 Vincent CA. Understanding and Responding to Adverse Events. New Engl J Med. 2003;348(11):1051- 1056. doi:10.1056/nejmhpr020760. https://psnet.ahrq.gov/issue/understanding-and-responding-adverse-events In this article, Vincent describes the investiga…

5311. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840168/psn-pdf
      January 01, 2023 - The debrief imperative: building teaming competencies and team effectiveness. November 16, 2022 Tannenbaum SI, Greilich PE. The debrief imperative: building teaming competencies and team effectiveness. BMJ Qual Saf. 2023;32(3):125-128. doi:10.1136/bmjqs-2022-015259. https://psnet.ahrq.gov/issue/debrief-imperative-…

5312. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867451/psn-pdf
      January 21, 2025 - Engineering Safety into Practice through Implementation of the EHR SAFER Guides. January 8, 2025 National Action Alliance for Patient and Workforce Safety. Engineering Safety into Practice through Implementation of the EHR SAFER Guides. January 21, 2025, 12:00 - 1:00 PM (eastern). https://psnet.ahrq.gov/issue/engi…

5313. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46727/psn-pdf
      August 21, 2021 - Alliance for Innovation on Maternal Health. August 21, 2021 American College of Obstetricians and Gynecologists. https://psnet.ahrq.gov/issue/alliance-innovation-maternal-health This website provides information from a multidisciplinary collaboration whose mission was to support safe health care for pregnant and p…

5314. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44054/psn-pdf
      November 16, 2015 - Analysis of ISMP National Vaccine Errors Reporting Program—part 1 and part 2. November 16, 2015 ISMP Medication Safety Alert! Acute Care Edition. December 4, 2014;19:1-6. March 26, 2015;20:1-4. https://psnet.ahrq.gov/issue/analysis-ismp-national-vaccine-errors-reporting-program-part-1-and-part-2 This newsletter se…

5315. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60990/psn-pdf
      October 07, 2020 - Tiered daily huddles: the power of teamwork in managing large healthcare organisations. October 7, 2020 Mihaljevic T. Tiered daily huddles: the power of teamwork in managing large healthcare organisations. BMJ Qual Saf. 2020;29(12):1050-1052. doi:10.1136/bmjqs-2019-010575. https://psnet.ahrq.gov/issue/tiered-daily…

5316. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46160/psn-pdf
      June 07, 2017 - ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults. June 7, 2017 Horsham, PA: Institute for Safe Medication Practices; May 2017. https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-subcutaneous-insulin-use-adults Insulin is a widely used medication that can contribute to serious patien…

5317. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43297/psn-pdf
      June 25, 2014 - The limits of checklists: handoff and narrative thinking. June 25, 2014 Hilligoss B, Moffatt-Bruce SD. The limits of checklists: handoff and narrative thinking. BMJ Qual Saf. 2014;23(7):528-33. doi:10.1136/bmjqs-2013-002705. https://psnet.ahrq.gov/issue/limits-checklists-handoff-and-narrative-thinking Communicatio…

5318. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44272/psn-pdf
      November 06, 2015 - Technology, cognition and error. November 6, 2015 Coiera E. Technology, cognition and error. BMJ Qual Saf. 2015;24(7):417-22. doi:10.1136/bmjqs-2014- 003484. https://psnet.ahrq.gov/issue/technology-cognition-and-error Providers and policymakers have raised concerns about risks associated with health information t…

5319. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837024/psn-pdf
      May 04, 2022 - The potential for leveraging machine learning to filter medication alerts. May 4, 2022 Liu S, Kawamoto K, Del Fiol G, et al. The potential for leveraging machine learning to filter medication alerts. J Am Med Inform Assoc. 2022;29(5):891-899. doi:10.1093/jamia/ocab292. https://psnet.ahrq.gov/issue/potential-levera…

5320. Save the Date for QSC 2025 | PSNet
      psnet.ahrq.gov/training-catalog/save-date-qsc-2025
      January 01, 2025 - Save the Date for QSC 2025 Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Organization: Organization American College of Surgeons (ACS) Event Description: Mark your ca…