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  1. www.ahrq.gov/topics/burnout.html
    Topic: Burnout Burnout is a serious and growing problem in many healthcare settings. Burnout can increase worker turnover and reduce quality of care, leading to lower patient satisfaction and patient safety as well as higher costs of care. AHRQ supports a wide range of projects to assess and reduce burnout among clin…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38202/psn-pdf
    November 12, 2008 - The tipping point: the relationship between volume and patient harm. November 12, 2008 Pedroja AT. The tipping point: the relationship between volume and patient harm. Am J Med Qual. 2008;23(5):336-41. doi:10.1177/1062860608320628. https://psnet.ahrq.gov/issue/tipping-point-relationship-between-volume-and-patient-…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39448/psn-pdf
    May 20, 2015 - A Patient Safety Handbook for Ambulatory Care Providers. May 20, 2015 Oak Brook, IL: Joint Commission Resources; 2009. ISBN: 9781599403670. https://psnet.ahrq.gov/issue/patient-safety-handbook-ambulatory-care-providers This guide offers tools and strategies to ensure that care in the ambulatory setting is safely p…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35833/psn-pdf
    July 23, 2010 - Medication administration errors: understanding the issues. July 23, 2010 McBride-Henry K, Foureur M. Medication administration errors: understanding the issues. Aust J Adv Nurs. 2006;23(3):33-41. https://psnet.ahrq.gov/issue/medication-administration-errors-understanding-issues The authors review the literature …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36587/psn-pdf
    January 14, 2011 - The value of inking breast cores to reduce specimen mix- up. January 14, 2011 Renshaw AA, Kish R, Gould EW. The value of inking breast cores to reduce specimen mix-up. Am J Clin Pathol. 2007;127(2):271-2. https://psnet.ahrq.gov/issue/value-inking-breast-cores-reduce-specimen-mix The authors describe a tissue spec…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43267/psn-pdf
    June 11, 2014 - The PROTECT Initiative: Advancing Children's Medication Safety. June 11, 2014 US Centers for Disease Control and Prevention. https://psnet.ahrq.gov/issue/protect-initiative-advancing-childrens-medication-safety This Web site offers resources related to a collaborative involving public health agencies, private org…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35033/psn-pdf
    May 18, 2005 - Medical errors still claiming many lives. May 18, 2005 Weise E. USA Today. May 18, 2005. https://psnet.ahrq.gov/issue/medical-errors-still-claiming-many-lives This article highlights a commentary published in JAMA by two leading experts in patient safety which summarizes the progress made since publication of the …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41665/psn-pdf
    September 12, 2012 - Risk factors associated with incorrect surgical counts. September 12, 2012 Rowlands A. Risk factors associated with incorrect surgical counts. AORN J. 2012;96(3):272-84. doi:10.1016/j.aorn.2012.06.012. https://psnet.ahrq.gov/issue/risk-factors-associated-incorrect-surgical-counts This study explored factors leadin…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38978/psn-pdf
    January 04, 2010 - Unintended exposure in radiotherapy: identification of prominent causes. January 4, 2010 Boadu M, Rehani MM. Unintended exposure in radiotherapy: identification of prominent causes. Radiother Oncol. 2009;93(3):609-17. doi:10.1016/j.radonc.2009.08.044. https://psnet.ahrq.gov/issue/unintended-exposure-radiotherapy-i…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40718/psn-pdf
    August 31, 2011 - Misinformation in the medical literature: what role do error and fraud play? August 31, 2011 Steen G. Misinformation in the medical literature: what role do error and fraud play? J Med Ethics. 2011;37(8):498-503. doi:10.1136/jme.2010.041830. https://psnet.ahrq.gov/issue/misinformation-medical-literature-what-role-…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38979/psn-pdf
    October 14, 2009 - Active learning: when is more better? The case of resident physicians' medical errors. October 14, 2009 Katz-Navon T; Naveh E; Stern Z. https://psnet.ahrq.gov/issue/active-learning-when-more-better-case-resident-physicians-medical-errors Establishing an active learning climate, in which resident physicians are enc…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37851/psn-pdf
    June 18, 2008 - Medical errors affecting the pediatric intensive care patient: incidence, identification, and practical solutions. June 18, 2008 Nichter MA. https://psnet.ahrq.gov/issue/medical-errors-affecting-pediatric-intensive-care-patient-incidence- identification-and This article reviews how the complexity of care in the p…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36960/psn-pdf
    September 12, 2011 - Profiles in patient safety: a "perfect storm" in the emergency department. September 12, 2011 Campbell SG, Croskerry P, Bond WF. Profiles in patient safety: A "perfect storm" in the emergency department. Acad Emerg Med. 2007;14(8):743-9. https://psnet.ahrq.gov/issue/profiles-patient-safety-perfect-storm-emergency-…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41060/psn-pdf
    September 06, 2013 - Flaws in clinical reasoning: a common cause of diagnostic error. September 6, 2013 Wellbery C. Flaws in clinical reasoning: a common cause of diagnostic error. Am Fam Physician. 2011;84(9):1042-8. https://psnet.ahrq.gov/issue/flaws-clinical-reasoning-common-cause-diagnostic-error Through an illustrative case repo…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42799/psn-pdf
    December 04, 2013 - All can be lost: the risk of putting our knowledge in the hands of machines. December 4, 2013 Carr N. The Atlantic. November 2013. https://psnet.ahrq.gov/issue/all-can-be-lost-risk-putting-our-knowledge-hands-machines Increasingly, computerized systems are performing more complex tasks in high-risk industries like…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44632/psn-pdf
    March 24, 2016 - Clash in the name of care. March 24, 2016 Abelson J, Saltzman J, Kowalcyzk L, Allen S. Boston Globe. October 26, 2015. https://psnet.ahrq.gov/issue/clash-name-care Scheduling concurrent surgeries can have negative effects on staff and patients. This investigative news article explores the practice of overlapping p…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38931/psn-pdf
    April 18, 2011 - Patient safety in intensive care medicine: the Declaration of Vienna. April 18, 2011 Moreno RP, Rhodes A, Donchin Y. Patient safety in intensive care medicine: the Declaration of Vienna. Intensive Care Med. 2009;35(10). doi:10.1007/s00134-009-1621-2. https://psnet.ahrq.gov/issue/patient-safety-intensive-care-medic…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867769/psn-pdf
    March 12, 2025 - Lessons from Event Reports. March 12, 2025 Lessons from Event Reports. Patient Safety Authority. https://psnet.ahrq.gov/issue/lessons-event-reports Small successes can inform and motivate actions leading to sustainable, evidence-based change. This searchable collection of projects initiated in response to event re…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34958/psn-pdf
    June 14, 2011 - Patient safety in an interprofessional learning environment. June 14, 2011 Horsburgh M, Merry A, Seddon M. Patient safety in an interprofessional learning environment. Med Educ. 2005;39(5):512-3. https://psnet.ahrq.gov/issue/patient-safety-interprofessional-learning-environment The authors discuss a patient safet…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36146/psn-pdf
    February 05, 2019 - Guidelines for Design and Construction. February 5, 2019 St Louis, Missouri; Facilities Guidelines Institute; 2018. https://psnet.ahrq.gov/issue/guidelines-design-and-construction These updated guidelines include design changes, such as the adoption of private rooms to reduce medical error, interruptions, and hosp…