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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43459/psn-pdfAugust 27, 2014 - Serious Reportable Events. August 27, 2014 Nova Scotia Department of Health and Wellness. https://psnet.ahrq.gov/issue/serious-reportable-events Incident reporting systems are an important method for capturing, analyzing, and learning about a broad range of potential safety issues. This Web site provides access to… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45782/psn-pdfJanuary 18, 2017 - Standardization of inpatient handoff communication. January 18, 2017 Jewell JA. Standardization of Inpatient Handoff Communication. Pediatrics. 2016;138(5):e20162681. doi:10.1542/peds.2016-2681. https://psnet.ahrq.gov/issue/standardization-inpatient-handoff-communication Handoffs at shift changes are vulnerable to… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837516/psn-pdfJune 22, 2022 - Fostering ethical conduct through psychological safety. June 22, 2022 Ferrere A, Rider C, Renerte B et al. Sloan Manag Rev. Summer 2022;39-43. https://psnet.ahrq.gov/issue/fostering-ethical-conduct-through-psychological-safety A baseline expectation in a safe organization is that employees feel comfortable and supp… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47544/psn-pdfDecember 12, 2018 - Using good catches to promote a just culture and perioperative patient safety. December 12, 2018 Monahan JJ. Using Good Catches to Promote a Just Culture and Perioperative Patient Safety. AORN J. 2018;108(5):548-552. doi:10.1002/aorn.12394. https://psnet.ahrq.gov/issue/using-good-catches-promote-just-culture-and-p… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37344/psn-pdfMarch 28, 2012 - Introduction of an obstetric-specific medical emergency team for obstetric crises: implementation and experience. March 28, 2012 Gosman GG, Baldisseri MR, Stein KL, et al. Introduction of an obstetric-specific medical emergency team for obstetric crises: implementation and experience. Am J Obstet Gynecol. 2008;198(… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45440/psn-pdfNovember 09, 2016 - Safety lessons from the NIH Clinical Center. November 9, 2016 Gandhi TK. Safety Lessons from the NIH Clinical Center. N Engl J Med. 2016;375(18):1705-1707. https://psnet.ahrq.gov/issue/safety-lessons-nih-clinical-center System failures can remain undetected over time in large organizations. This perspective describ… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44625/psn-pdfNovember 20, 2015 - State-of-the-art usage of simulation in anesthesia: skills and teamwork. November 20, 2015 Krage R, Erwteman M. State-of-the-art usage of simulation in anesthesia: skills and teamwork. Curr Opin Anaesthesiol. 2015;28(6):727-34. doi:10.1097/ACO.0000000000000257. https://psnet.ahrq.gov/issue/state-art-usage-simulati… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837211/psn-pdfMay 25, 2022 - 4 actions to reduce medical errors in U.S. hospitals. May 25, 2022 Toussaint JS, Segel KT. Harvard Business Review. April 20, 2022. https://psnet.ahrq.gov/issue/4-actions-reduce-medical-errors-us-hospitals The patient safety movement has had mixed results in sustaining improvement and commitment. This comment… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/50428/psn-pdfSeptember 04, 2019 - Patient safety incidents caused by poor quality surgical instruments. September 4, 2019 Dominguez ED, Rocos B. Patient Safety Incidents Caused by Poor Quality Surgical Instruments. Cureus. 2019;11(6):e4877. doi:10.7759/cureus.4877. https://psnet.ahrq.gov/issue/patient-safety-incidents-caused-poor-quality-surgical-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/851199/psn-pdfJuly 05, 2023 - Understanding the root cause analysis process to increase safety event reporting. July 5, 2023 Dudley KA. Understanding the root cause analysis process to increase safety event reporting. AORN J. 2023;117(6):399-402. doi:10.1002/aorn.13935. https://psnet.ahrq.gov/issue/understanding-root-cause-analysis-process-inc… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/865719/psn-pdfMay 01, 2024 - High reliability pediatric heart centers: always working toward getting better. May 1, 2024 Torzone A, Birely A. High reliability pediatric heart centers: always working toward getting better. Curr Opin Cardiol. 2024;39(4):356-363. doi:10.1097/hco.0000000000001143. https://psnet.ahrq.gov/issue/high-reliability-ped… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46564/psn-pdfDecember 06, 2017 - Can the aviation industry be useful in teaching oncology about safety? December 6, 2017 Davies JM, Delaney G. Can the Aviation Industry be Useful in Teaching Oncology about Safety? Clin Oncol (R Coll Radiol). 2017;29(10):669-675. doi:10.1016/j.clon.2017.06.007. https://psnet.ahrq.gov/issue/can-aviation-industry-be… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/838030/psn-pdfSeptember 07, 2022 - Rethinking use of air-safety principles to reduce fatal hospital errors. September 7, 2022 Rethinking use of air-safety principles to reduce fatal hospital errors. doi:10.1377/forefront.20220824.965364. https://psnet.ahrq.gov/issue/rethinking-use-air-safety-principles-reduce-fatal-hospital-errors The safety of co… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44781/psn-pdfJanuary 13, 2016 - Improving Pediatric Surgery Quality and Outcomes in the 21st Century. January 13, 2016 Heiss K, ed. Semin Pediatr Surg. 2015;24:265-326. https://psnet.ahrq.gov/issue/improving-pediatric-surgery-quality-and-outcomes-21st-century Articles in this special issue introduce quality improvement principles, such as system… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44425/psn-pdfFebruary 24, 2016 - Dangerous doses. February 24, 2016 Roe S, King K. Chicago Tribune. February 10–13, 2016. https://psnet.ahrq.gov/issue/dangerous-doses Drug interactions can be hazardous to patients, particularly when combined with risk factors such as age and use of medications for chronic conditions. This series of news reports d… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45264/psn-pdfSeptember 01, 2016 - Perceived factors associated with sustained improvement following participation in a multicenter quality improvement collaborative. September 1, 2016 Stone S, Lee HC, Sharek PJ. Perceived Factors Associated with Sustained Improvement Following Participation in a Multicenter Quality Improvement Collaborative. Jt Co… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/854832/psn-pdfOctober 25, 2023 - Achieving a successful patient safety program with implementation of a harm reduction strategy. October 25, 2023 Cohen JB. APSF Newsletter. 2023;38(10):93-95. https://psnet.ahrq.gov/issue/achieving-successful-patient-safety-program-implementation-harm-reduction- strategy Zero harm, while a laudable goal, has been… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43686/psn-pdfNovember 26, 2014 - Tools for primary care patient safety: a narrative review. November 26, 2014 Spencer R, Campbell S. Tools for primary care patient safety: a narrative review. BMC Fam Pract. 2014;15:166. doi:10.1186/1471-2296-15-166. https://psnet.ahrq.gov/issue/tools-primary-care-patient-safety-narrative-review Proven methods to … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46371/psn-pdfFebruary 14, 2018 - Changing operating room culture: implementation of a postoperative debrief and improved safety culture. February 14, 2018 Magill ST, Wang DD, Rutledge C, et al. Changing Operating Room Culture: Implementation of a Postoperative Debrief and Improved Safety Culture. World Neurosurg. 2017;107:597-603. doi:10.1016/j.w… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45188/psn-pdfJune 01, 2016 - Reporting and second-order problem solving can turn short-term fixes into long-term remedies. June 1, 2016 ISMP Medication Safety Alert! Acute Care Edition. May 19, 2016;21:1-4. https://psnet.ahrq.gov/issue/reporting-and-second-order-problem-solving-can-turn-short-term-fixes-long- term-remedies Workarounds are pr…
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