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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41165/psn-pdf
    December 08, 2016 - IHI Open School Patient Safety Curriculum December 8, 2016 Institute for Healthcare Improvement. https://psnet.ahrq.gov/issue/patient-safety-curriculum-2nd-edition There is a documented interest in postgraduate professional education that enables practicing clinicians to improve the safety of their actions and beh…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36860/psn-pdf
    January 20, 2016 - IHI Global Trigger Tool for Measuring Adverse Events. 2nd Edition. January 20, 2016 Griffin FA, Resar RK. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2009. https://psnet.ahrq.gov/issue/ihi-global-trigger-tool-measuring-adverse-events-2nd-edition This white paper describ…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865570/psn-pdf
    April 10, 2024 - Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner April 10, 2024 https://psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive- approach-data Summary North American Partners…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865698/psn-pdf
    April 24, 2024 - Patient Safety Amid Nursing Workforce Challenges April 24, 2024 Leary KB, Lee M, Mossburg S. Patient Safety Amid Nursing Workforce Challenges . PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges Introduction Nurses are essential to patient care, and having a…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49853/psn-pdf
    February 01, 2019 - Adverse Event During Intrahospital Transport February 1, 2019 Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport The Case A 4-year-old boy underwent surgery under general anesthesia for correction o…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49465/psn-pdf
    December 22, 2021 - Electronic Err October 1, 2004 Tang PC. Electronic Err. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/electronic-err The Case A 75-year-old woman with coronary artery disease presented to the emergency department (ED) with chest pain that that had not responded to three sublingual nitroglycerin tablets at…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49616/psn-pdf
    December 01, 2010 - Milliliters vs. Milligrams December 1, 2010 Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/milliliters-vs-milligrams The Case   A 32-year-old man was admitted to the hospital after a vehicle collision and multiple traumatic injuries. His evaluation showed acu…
  8. psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat
    February 26, 2025 - May 20, 2019 Engaging residents and fellows to improve institution-wide quality: the
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45624/psn-pdf
    November 02, 2016 - Addressing the Opioid Crisis in the United States. November 2, 2016 Martin L, Laderman M, Hyatt J, Krueger J. Cambridge, MA: Institute for Healthcare Improvement; April 2016. https://psnet.ahrq.gov/issue/addressing-opioid-crisis-united-states Misuse of opioid medications is currently a serious patient safety conce…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43328/psn-pdf
    August 20, 2018 - Safety Quality and Informatics Leadership Program. August 20, 2018 Harvard Medical School, Boston, MA https://psnet.ahrq.gov/issue/safety-quality-and-informatics-leadership-program The Institute of Medicine's learning health system concept serves as the foundation for this year-long curriculum covering how to appl…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47966/psn-pdf
    May 29, 2019 - Patient Safety Essentials Toolkit. May 29, 2019 Boston, MA: Institute for Healthcare Improvement; 2019. https://psnet.ahrq.gov/issue/patient-safety-essentials-toolkit This toolkit provides access to nine key tools to help organizations improve teamwork, incident analysis, and communication as well as templates to …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41407/psn-pdf
    June 19, 2012 - Error disclosure: a new domain for safety culture assessment. June 19, 2012 Etchegaray J, Gallagher TH, Bell SK, et al. Error disclosure: a new domain for safety culture assessment. BMJ Qual Saf. 2012;21(7):594-9. doi:10.1136/bmjqs-2011-000530. https://psnet.ahrq.gov/issue/error-disclosure-new-domain-safety-cultur…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44917/psn-pdf
    November 30, 2016 - Canadian Incident Analysis Framework. November 30, 2016 Incident Analysis Collaborating Parties. Edmonton, AB: Canadian Patient Safety Institute; 2012. ISBN: 9781926541440. https://psnet.ahrq.gov/issue/canadian-incident-analysis-framework Performing incident analysis can help organizations understand why adverse e…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35283/psn-pdf
    July 14, 2010 - Hospitalists as emerging leaders in patient safety: targeting a few to affect many. July 14, 2010 Flanders SA, Kaufman SR, Saint S, et al. Hospitalists as emerging leaders in patient safety: targeting a few to affect many. J Patient Saf. 2005;1(2):78-82. doi:10.1097/pts.0b013e31819751f2. https://psnet.ahrq.gov/iss…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60189/psn-pdf
    April 01, 2020 - Eliminating Medication Overload: A National Action Plan. April 1, 2020 Working Group on Medication Overload. Brookline, MA: Lown Institute; 2020. https://psnet.ahrq.gov/issue/eliminating-medication-overload-national-action-plan Polypharmacy and medication overuse are known contributors to patient harm. This report …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42812/psn-pdf
    August 02, 2016 - Healthcare Practitioner’s Vaccine Error Reporting Form. August 2, 2016 Institute for Safe Medication Practices. https://psnet.ahrq.gov/issue/healthcare-practitioners-vaccine-error-reporting-form This form collects data on errors and concerns associated with vaccines as part of a national reporting program tracking…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34733/psn-pdf
    November 19, 2015 - Out of the Crisis. November 19, 2015 Deming WE. Cambridge, MA: Massachusetts Institute of Technology, Center for Advanced Engineering Study, 1986. ISBN: 9780911379013. https://psnet.ahrq.gov/issue/out-crisis Deming believes that American companies need to transform their method of management to engage and compete…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863762/psn-pdf
    March 14, 2024 - Diagnostic Excellence: a Patient Safety Awareness Week Webinar. March 6, 2024 Institute for Healthcare Improvement. March 14, 2024. https://psnet.ahrq.gov/issue/diagnostic-excellence-patient-safety-awareness-week-webinar Diagnostic safety is core to care without harm. This webinar aligned with the 2024 Patient Saf…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44007/psn-pdf
    April 01, 2015 - Time to tackle diagnostic errors. Physicians blame patient 'treadmill' for missed calls. April 1, 2015 Rice S. Time to tackle diagnostic errors. Physicians blame patient 'treadmill' for missed calls. Modern healthcare. 2015;45(3):18-20. https://psnet.ahrq.gov/issue/time-tackle-diagnostic-errors-physicians-blame-pa…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44115/psn-pdf
    June 03, 2015 - An approach to assessing patient safety in hospitals in low-income countries. June 3, 2015 Lindfield R, Knight A, Bwonya D. An approach to assessing patient safety in hospitals in low-income countries. PLoS One. 2015;10(3):e0121628. doi:10.1371/journal.pone.0121628. https://psnet.ahrq.gov/issue/approach-assessing-…

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