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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46197/psn-pdf
    September 24, 2017 - Implementation and evaluation of a prototype consumer reporting system for patient safety events. September 24, 2017 Weingart SN, Weissman JS, Zimmer KP, et al. Implementation and evaluation of a prototype consumer reporting system for patient safety events. Int J Qual Health Care. 2017;29(4):521-526. doi:10.1093/…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45535/psn-pdf
    January 23, 2017 - Surgical specimen management: a descriptive study of 648 adverse events and near misses. January 23, 2017 Steelman VM, Williams TL, Szekendi MK, et al. Surgical specimen management: a descriptive study of 648 adverse events and near misses. Arch Pathol Lab Med. 2016;140(12):1390-1396. https://psnet.ahrq.gov/issue/…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39456/psn-pdf
    May 04, 2010 - Accuracy of computer-generated, Spanish-language medicine labels. May 4, 2010 Sharif I, Tse J. Accuracy of computer-generated, spanish-language medicine labels. Pediatrics. 2010;125(5):960-5. doi:10.1542/peds.2009-2530. https://psnet.ahrq.gov/issue/accuracy-computer-generated-spanish-language-medicine-labels Misu…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39193/psn-pdf
    April 21, 2011 - Disclosing harmful mammography errors to patients. April 21, 2011 Gallagher TH, Cook AJ, Brenner RJ, et al. Disclosing Harmful Mammography Errors to Patients. Radiology. 2009;253(2). doi:10.1148/radiol.2532082320. https://psnet.ahrq.gov/issue/disclosing-harmful-mammography-errors-patients Disclosing errors to pati…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37803/psn-pdf
    January 06, 2017 - Paying the piper: investing in infrastructure for patient safety.  January 6, 2017 Pronovost P, Rosenstein BJ, Paine LA, et al. Paying the piper: investing in infrastructure for patient safety. Jt Comm J Qual Patient Saf. 2008;34(6):342-8. https://psnet.ahrq.gov/issue/paying-piper-investing-infrastructure-patient-…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851348/psn-pdf
    July 12, 2023 - Widespread misinterpretation of advance directives and Portable Orders for Life-Sustaining Treatments threatens patient safety and causes undertreatment and overtreatment. July 12, 2023 Mirarchi FL, Pope TM. Widespread misinterpretation of advance directives and Portable Orders for Life- Sustaining Treatments thr…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41572/psn-pdf
    October 29, 2012 - Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. October 29, 2012 Winters BD, Custer J, Galvagno SM, et al. Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. BMJ Qual Saf. 2012;21(11):894-902. doi:10.1136/bmjqs-2012-000803. https://psnet.ahrq…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41250/psn-pdf
    December 21, 2014 - Disclosure of "nonharmful" medical errors and other events: duty to disclose. December 21, 2014 Chamberlain CJ, Koniaris LG, Wu AW, et al. Disclosure of "nonharmful" medical errors and other events: duty to disclose. Arch Surg. 2012;147(3):282-6. doi:10.1001/archsurg.2011.1005. https://psnet.ahrq.gov/issue/disclos…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42178/psn-pdf
    April 10, 2013 - Outside case review of surgical pathology for referred patients: the impact on patient care. April 10, 2013 Swapp RE, Aubry MC, Salomão DR, et al. Outside case review of surgical pathology for referred patients: the impact on patient care. Arch Pathol Lab Med. 2013;137(2):233-40. doi:10.5858/arpa.2012-0088-OA. htt…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/862991/psn-pdf
    February 21, 2024 - Exploring the role of guidelines in contributing to medication errors: a descriptive analysis of national patient safety incident data. February 21, 2024 Jones MD, Liu S, Powell F, et al. Exploring the role of guidelines in contributing to medication errors: a descriptive analysis of national patient safety incide…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37386/psn-pdf
    January 06, 2017 - Medication reconciliation in ambulatory oncology. January 6, 2017 Weingart SN, Cleary A, Seger AC, et al. Medication reconciliation in ambulatory oncology. Jt Comm J Qual Patient Saf. 2007;33(12):750-7. https://psnet.ahrq.gov/issue/medication-reconciliation-ambulatory-oncology The Joint Commission mandates systems…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43567/psn-pdf
    October 21, 2016 - National Action Plan for Adverse Drug Event Prevention. October 21, 2016 Washington, DC: Office of Disease Prevention and Health Promotion, United States Department of Health and Human Services; September 2014. https://psnet.ahrq.gov/issue/national-action-plan-adverse-drug-event-prevention This national action pla…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60539/psn-pdf
    July 10, 2017 - Understanding facilitators and barriers to care transitions: insights from Project ACHIEVE Site Visits. July 10, 2017 Scott AM, Li J, Oyewole-Eletu S, et al. Understanding facilitators and barriers to care transitions: insights from Project ACHIEVE Site Visits. Jt Comm J Qual Patient Saf. 2017;43(9):433-447. doi:1…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60185/psn-pdf
    April 01, 2020 - Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation. April 1, 2020 Oliva EM, Bowe T, Manhapra A, et al. Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suici…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39581/psn-pdf
    January 03, 2017 - An implementation strategy for a multicenter pediatric rapid response system in Ontario. January 3, 2017 Buist MD, Shearer W. Rapid Response Systems: A Mandatory System of Care or an Optional Extra for Bedside Clinical Staff? The Joint Commission Journal on Quality and Patient Safety. 2016;36(6). doi:10.1016/s1553…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47561/psn-pdf
    February 22, 2019 - "Change is what can actually make the tough times better": a patient-centred patient safety intervention delivered in collaboration with hospital volunteers. February 22, 2019 Louch G, Mohammed MA, Hughes L, et al. "Change is what can actually make the tough times better": A patient-centred patient safety interven…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73364/psn-pdf
    January 01, 2022 - Impact of opioid administration in the intensive care unit and subsequent use in opioid-naïve patients. June 9, 2021 Krancevich NM, Belfer JJ, Draper HM, et al. Impact of opioid administration in the intensive care unit and subsequent use in opioid-naïve patients. Ann Pharmacother. 2022;56(1):52-59. doi:10.1177/10…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836719/psn-pdf
    March 09, 2022 - Prevalence and factors associated with patient-requested corrections to the medical record through use of a patient portal: findings from a national survey. March 9, 2022 Nguyen OT, Hong Y-R, Alishahi Tabriz A, et al. Prevalence and factors associated with patient-requested corrections to the medical record throug…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37776/psn-pdf
    January 31, 2011 - Barcoded medication administration: a last line of defense. January 31, 2011 Cescon DW, Etchells E. Barcoded medication administration: a last line of defense. JAMA. 2008;299(18):2200-2. doi:10.1001/jama.299.18.2200. https://psnet.ahrq.gov/issue/barcoded-medication-administration-last-line-defense Barcoding techn…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60591/psn-pdf
    June 17, 2020 - National trends in the safety performance of electronic health record systems from 2009 to 2018. June 17, 2020 Classen DC, Holmgren AJ, Co Z, et al. National trends in the safety performance of electronic health record systems from 2009 to 2018. JAMA Netw Open. 2020;3(5). doi:10.1001/jamanetworkopen.2020.5547. htt…
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