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1901. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837208/psn-pdf
      May 25, 2022 - Interprofessional model on speaking up behaviour in healthcare professionals: a qualitative study. May 25, 2022 Umoren R, Kim S, Gray MM, et al. Interprofessional model on speaking up behaviour in healthcare professionals: a qualitative study. BMJ Lead. 2022;6(1):15-19. doi:10.1136/leader-2020-000407. https://psne…

1902. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41464/psn-pdf
      November 26, 2014 - Risk of unintentional overdose with non-prescription acetaminophen products. November 26, 2014 Wolf MS, King J, Jacobson K, et al. Risk of unintentional overdose with non-prescription acetaminophen products. J Gen Intern Med. 2012;27(12):1587-93. doi:10.1007/s11606-012-2096-3. https://psnet.ahrq.gov/issue/risk-uni…

1903. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44809/psn-pdf
      March 02, 2016 - Seniors managing multiple medications: using mixed methods to view the home care safety lens. March 2, 2016 Lang A, Macdonald M, Marck P, et al. Seniors managing multiple medications: using mixed methods to view the home care safety lens. BMC Health Serv Res. 2015;15:548. doi:10.1186/s12913-015-1193-5. https://psn…

1904. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851353/psn-pdf
      July 12, 2023 - Caregiver and clinician perspectives on discharge medication counseling: a qualitative study. July 12, 2023 Carroll AR, Schlundt D, Bonnet K, et al. Caregiver and clinician perspectives on discharge medication counseling: a qualitative study. Hosp Pediatr. 2023;13(4):325-342. doi:10.1542/hpeds.2022-006937. https:/…

1905. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40191/psn-pdf
      May 28, 2014 - The Value of Close Calls in Improving Patient Safety. May 28, 2014 Wu AW, ed. Oakbrook Terrace, IL: Joint Commission Resources; 2011. ISBN: 9781599404158. https://psnet.ahrq.gov/issue/value-close-calls-improving-patient-safety Close calls (sometimes called near misses) pose unique challenges and opportunities when …

1906. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837025/psn-pdf
      May 04, 2022 - Central venous catheter guidewire retention: lessons from England's never event database. May 4, 2022 Mariyaselvam MZA, Patel V, Young HE, et al. Central venous catheter guidewire retention: lessons from England's never event database. J Patient Saf. 2022;18(2):e387-e392. doi:10.1097/pts.0000000000000826. https:/…

1907. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836823/psn-pdf
      March 30, 2022 - Five-year audit of adherence to an anaesthesia pre- induction checklist. March 30, 2022 Fuchs A, Frick S, Huber M, et al. Five?year audit of adherence to an anaesthesia pre?induction checklist. Anaesthesia. 2022;77(7):751-762. doi:10.1111/anae.15704. https://psnet.ahrq.gov/issue/five-year-audit-adherence-anaesthes…

1908. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46370/psn-pdf
      November 08, 2017 - Standard admission order sets promote ordering of unnecessary investigations: a quasi-randomised evaluation in a simulated setting. November 8, 2017 Leis B, Frost A, Bryce R, et al. Standard admission order sets promote ordering of unnecessary investigations: a quasi-randomised evaluation in a simulated setting. B…

1909. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60175/psn-pdf
      April 01, 2020 - ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection. April 1, 2020 American College of Radiology. March 11, 2020. https://psnet.ahrq.gov/issue/acr-recommendations-use-chest-radiography-and-computed-tomography-ct- suspected-covid-19 As COVID-19 s…

1910. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46014/psn-pdf
      April 05, 2017 - Immersive high fidelity simulation of critically ill patients to study cognitive errors: a pilot study. April 5, 2017 Prakash S, Bihari S, Need P, et al. Immersive high fidelity simulation of critically ill patients to study cognitive errors: a pilot study. BMC Med Educ. 2017;17(1):36. doi:10.1186/s12909-017-0871-x…

1911. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44688/psn-pdf
      February 23, 2018 - Improving diagnosis in health care—the next imperative for patient safety. February 23, 2018 Singh H, Graber ML. Improving Diagnosis in Health Care--The Next Imperative for Patient Safety. New Engl J Med. 2015;373(26):2493-2495. doi:10.1056/NEJMp1512241. https://psnet.ahrq.gov/issue/improving-diagnosis-health-care…

1912. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866202/psn-pdf
      July 24, 2024 - Medication Without Harm - How Digital Healthcare Tools Can Support Providers and Improve Patient Safety. June 26, 2024 Agency for Healthcare Research and Quality. July 24, 2024. https://psnet.ahrq.gov/issue/medication-without-harm-how-digital-healthcare-tools-can-support-providers- and-improve Medication errors a…

1913. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73709/psn-pdf
      September 15, 2021 - Crisis management for surgical teams and their leaders, lessons from the COVID-19 pandemic; a structured approach to developing resilience or natural organisational responses. September 15, 2021 Pring ET, Malietzis G, Kendall SWH, et al. Crisis management for surgical teams and their leaders, lessons from the COV…

1914. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47376/psn-pdf
      November 02, 2018 - Assessing information sources to elucidate diagnostic process errors in radiologic imaging—a human factors framework. November 2, 2018 Cochon L, Lacson R, Wang A, et al. Assessing information sources to elucidate diagnostic process errors in radiologic imaging - a human factors framework. J Am Med Info Asso. 2018;…

1915. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836915/psn-pdf
      April 13, 2022 - Workarounds in electronic health record systems and the revised Sociotechnical Electronic Health Record Workaround Analysis Framework: scoping review. April 13, 2022 Blijleven V, Hoxha F, Jaspers MWM. Workarounds in electronic health record systems and the revised sociotechnical Electronic Health Record workaround…

1916. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848366/psn-pdf
      May 03, 2023 - The effect of documenting patient weight in kilograms on pediatric medication dosing errors in emergency medical services. May 3, 2023 Ward CE, Taylor M, Keeney C, et al. The effect of documenting patient weight in kilograms on pediatric medication dosing errors in emergency medical services. Prehosp Emerg Care. 2…

1917. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837698/psn-pdf
      July 20, 2022 - White patients’ physical responses to healthcare treatments are influenced by provider race and gender. July 20, 2022 Howe LC, Hardebeck EJ, Eberhardt JL, et al. White patients’ physical responses to healthcare treatments are influenced by provider race and gender. Proc Natl Acad Sci USA. 2022;119(27):e2007717119. …

1918. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836966/psn-pdf
      April 20, 2022 - Performance variability in perioperative sentinel events: report on a nationwide data set. April 20, 2022 Reijmerink IM, Bos K, Leistikow IP, et al. Performance variability in perioperative sentinel events: report on a nationwide data set. Br J Surg. 2022;109(7):573-575. doi:10.1093/bjs/znac067. https://psnet.ahrq…

1919. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72664/psn-pdf
      January 20, 2021 - Delayed flow is a risk to patient safety: a mixed method analysis of emergency department patient flow. January 20, 2021 Pryce A, Unwin M, Kinsman L, et al. Delayed flow is a risk to patient safety: A mixed method analysis of emergency department patient flow. Int Emerg Nurs. 2020;54:100956. doi:10.1016/j.ienj.2020…

1920. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60050/psn-pdf
      March 18, 2020 - Zero harm in health care. March 18, 2020 Gandhi TK, Feeley D, Schummers D. Zero Harm in Health Care. NEJM Catal Innov Care Deliv. 2020;1(2). doi:10.1056/cat.19.1137. https://psnet.ahrq.gov/issue/zero-harm-health-care Health systems are encouraged to strive for zero preventable harm, but achieving this goal require…