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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43941/psn-pdf
    February 25, 2015 - How to make surgery safer. February 25, 2015 https://psnet.ahrq.gov/issue/how-make-surgery-safer This newspaper article reports on various ways hospitals are working to make surgical care safer and reduce readmissions due to surgical complications, including checklists, teamwork training courses for surgeons, preo…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40689/psn-pdf
    August 17, 2011 - Non-clinical errors using voice recognition dictation software for radiology reports: a retrospective audit. August 17, 2011 Chang CA, Strahan R, Jolley D. Non-clinical errors using voice recognition dictation software for radiology reports: a retrospective audit. J Digit Imaging. 2011;24(4):724-8. doi:10.1007/s102…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40285/psn-pdf
    March 09, 2011 - ASHP statement on bar-code verification during inventory, preparation, and dispensing of medications. March 9, 2011 ASHP statement on bar-code verification during inventory, preparation, and dispensing of medications. Am J Health-Syst Pharm. 2011;68:442-445. doi:10.2146/sp100012. https://psnet.ahrq.gov/issue/ashp-…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45237/psn-pdf
    June 15, 2016 - Medication reconciliation in oncological patients: a randomized clinical trial. June 15, 2016 Vega TG-C, Sierra-Sánchez JF, Martínez-Bautista MJ, et al. Medication Reconciliation in Oncological Patients: A Randomized Clinical Trial. J Manag Care Spec Pharm. 2016;22(6):734-40. doi:10.18553/jmcp.2016.15248. https:/…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73123/psn-pdf
    April 01, 2020 - Digital Healthcare Research. April 1, 2020 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/digital-healthcare-research An understanding of the impact that digital tools can have on clinical decision making, patient self-care, and health system improvement is still emerging. This website hi…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41416/psn-pdf
    May 23, 2012 - Checking anaesthetic equipment 2012: Association of Anaesthetists of Great Britain and Ireland. May 23, 2012 Anderson E, Bythell V, Gemmell L, et al. Checking Anaesthetic Equipment 2012. Anaesthesia. 2012;67(6). doi:10.1111/j.1365-2044.2012.07163.x. https://psnet.ahrq.gov/issue/checking-anaesthetic-equipment-2012-…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72562/psn-pdf
    December 09, 2020 - Missed or Rationed Nursing Care. December 9, 2020 J Nurs Manag. 2020;28(8): i-iv, 1767-2275. https://psnet.ahrq.gov/issue/missed-or-rationed-nursing-care Incomplete nursing care is known to affect care quality and safety. This special issue documents the global problem of missed or rationed nursing care in a varie…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47588/psn-pdf
    November 21, 2018 - 2 MSO programs show value of safety position. November 21, 2018 Wild D. Pharmacy Practice News. November 8, 2018. https://psnet.ahrq.gov/issue/2-mso-programs-show-value-safety-position Medication safety officers serve as organizational champions of medication management process improvement. This news article offer…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45311/psn-pdf
    May 20, 2019 - The Joint Commission Big Book of Checklists. 2nd Edition. May 20, 2019 Oakbrook Terrance, IL: Joint Commission; 2018. ISBN: 9781635850598. https://psnet.ahrq.gov/issue/joint-commission-big-book-checklists-2nd-edition Checklists are a widely accepted strategy to improve communication and standardize processes to su…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40728/psn-pdf
    October 21, 2011 - What prevents incident disclosure, and what can be done to promote it? October 21, 2011 Iedema R, Allen S, Sorensen R, et al. What prevents incident disclosure, and what can be done to promote it? Jt Comm J Qual Patient Saf. 2011;37(9):409-417. https://psnet.ahrq.gov/issue/what-prevents-incident-disclosure-and-wha…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43241/psn-pdf
    June 11, 2014 - "It is the left eye, right?" June 11, 2014 Pikkel D, Sharabi-Nov A, Pikkel J. "It is the left eye, right?". Risk Manag Healthc Policy. 2014;7:77-80. doi:10.2147/RMHP.S60728. https://psnet.ahrq.gov/issue/it-left-eye-right In this study, cataract surgeons were asked to identify the correct eye for surgery when given…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45338/psn-pdf
    July 20, 2016 - Understanding models of error and how they apply in clinical practice. July 20, 2016 Garfield S, Franklin BD. Pharm J. June 14, 2016. https://psnet.ahrq.gov/issue/understanding-models-error-and-how-they-apply-clinical-practice Human error and fallibility are a part of health care delivery that can be exacerbated b…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46607/psn-pdf
    November 08, 2017 - Stem the Tide: Addressing the Opioid Epidemic. November 8, 2017 Chicago, IL: American Hospital Association; 2017. https://psnet.ahrq.gov/issue/stem-tide-addressing-opioid-epidemic The opioid epidemic is a challenge to patient safety and public health. This report reviews tools to help health care systems target ei…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36221/psn-pdf
    October 20, 2010 - Enhancing patient safety during hand-offs: standardized communication and teamwork using the 'SBAR' method. October 20, 2010 Hohenhaus S, Powell S, Hohenhaus JT. Am J Nurs. 2006;106(8):72A-72B. https://psnet.ahrq.gov/issue/enhancing-patient-safety-during-hand-offs-standardized-communication-and- teamwork-using-sba…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50864/psn-pdf
    February 05, 2020 - I'm sorry: laws that support apologies in health care. February 5, 2020 Atkinson Smith M. I?m Sorry. Prof Case Manag. 2019;25(1):40-45. doi:10.1097/ncm.0000000000000410. https://psnet.ahrq.gov/issue/im-sorry-laws-support-apologies-health-care Apology laws have been passed by numerous states and the District of Colu…
  16. psnet.ahrq.gov/web-mm/see-patient-first
    September 27, 2023 - But See the Patient First Citation Text: Sinigayan VR. But See the Patient First. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49737/psn-pdf
    June 01, 2015 - Unseen Perils of Urinary Catheters June 1, 2015 Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters The Case A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33826/psn-pdf
    February 01, 2017 - In Conversation With… Amy C. Edmondson, PhD, AM February 1, 2017 In Conversation With… Amy C. Edmondson, PhD, AM. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am Editor's note: Dr. Edmondson is professor of Leadership and Management at Harvard Business School. Her la…
  19. psnet.ahrq.gov/classics
    August 01, 2023 - Classics and Emerging Classics To help our readers navigate the tremendous breadth of the PSNet Collection, AHRQ PSNet editors and advisors have given the designation of “Classic” to review articles, empirical studies, government and stakeholder reports, commentaries, and books of lasting importance to the patient sa…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838900/psn-pdf
    October 27, 2022 - Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. October 27, 2022 Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/fecal-contamination-…

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