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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41024/psn-pdf
    December 21, 2011 - Teamwork and team training in the ICU: where do the similarities with aviation end? December 21, 2011 Reader TW, Cuthbertson BH. Teamwork and team training in the ICU: Where do the similarities with aviation end? Crit Care. 2011;15(6). doi:10.1186/cc10353. https://psnet.ahrq.gov/issue/teamwork-and-team-training-ic…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50606/psn-pdf
    October 30, 2019 - One doctor. 25 deaths. How could it have happened? October 30, 2019 Healy J, Farr I, Feiger L, Duffy C. New York Times. October 11, 2019. https://psnet.ahrq.gov/issue/one-doctor-25-deaths-how-could-it-have-happened Systemic failures persistently undermine processes meant to keep patients safe. This news story discu…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44526/psn-pdf
    October 07, 2015 - The evolution of a safety culture. October 7, 2015 Patton BS, Donovan KJ. The Evolution of a Safety Culture. Air Med J. 2015;34(5):264-8. doi:10.1016/j.amj.2015.05.012. https://psnet.ahrq.gov/issue/evolution-safety-culture This commentary describes how an air transport unit at one hospital developed a safety cultu…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41856/psn-pdf
    November 21, 2012 - Electronic health records and National Patient-Safety Goals. November 21, 2012 Sittig DF, Singh H. Electronic Health Records and National Patient-Safety Goals. New England Journal of Medicine. 2012;367(19). doi:10.1056/nejmsb1205420. https://psnet.ahrq.gov/issue/electronic-health-records-and-national-patient-safet…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73572/psn-pdf
    August 04, 2021 - Center for Innovations in Quality, Effectiveness and Safety. IQuESt! August 4, 2021 Houston, TX:  Baylor College of Medicine. https://psnet.ahrq.gov/issue/center-innovations-quality-effectiveness-and-safety-iquest This Center represents a partnership with the Veterans Affairs Health Services Research & Develo…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39093/psn-pdf
    November 11, 2009 - For whom the Bell Commission tolls: unintended effects of limiting residents' hours. November 11, 2009 Millard WB. For whom the bell commission tolls: unintended effects of limiting residents' hours. Ann Emerg Med. 2009;54(4):A25-9. https://psnet.ahrq.gov/issue/whom-bell-commission-tolls-unintended-effects-limitin…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38982/psn-pdf
    February 03, 2011 - Association of resident fatigue and distress with perceived medical errors. February 3, 2011 West CP, Tan AD, Habermann TM, et al. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302(12):1294-300. doi:10.1001/jama.2009.1389. https://psnet.ahrq.gov/issue/association-resident-f…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36042/psn-pdf
    February 17, 2011 - Major congenital malformations after first-trimester exposure to ACE inhibitors. February 17, 2011 Cooper WO, Hernandez-Diaz S, Arbogast PG, et al. Major Congenital Malformations after First-Trimester Exposure to ACE Inhibitors. New England Journal of Medicine. 2006;354(23). doi:10.1056/nejmoa055202. https://psnet…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837862/psn-pdf
    August 17, 2022 - A California man’s ‘painful and terrifying’ road to a Monkeypox diagnosis. August 17, 2022 Fortiér J. Kaiser Health News. August 4, 2022. https://psnet.ahrq.gov/issue/california-mans-painful-and-terrifying-road-monkeypox-diagnosis Lack of familiarity with disease is known to contribute to missed and delayed diagno…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37872/psn-pdf
    January 11, 2017 - The effectiveness of root cause analysis: what does the literature tell us? January 11, 2017 Percarpio KB, Watts V, Weeks WB. The effectiveness of root cause analysis: what does the literature tell us? Jt Comm J Qual Patient Saf. 2008;34(7):391-8. https://psnet.ahrq.gov/issue/effectiveness-root-cause-analysis-what…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34754/psn-pdf
    February 06, 2018 - Patient Safety in Anesthetic Practice. February 6, 2018 Morell RC; Eichhorn JH, eds. New York: Churchill Livingstone, 1997. ISBN: 9780443076824. https://psnet.ahrq.gov/issue/patient-safety-anesthetic-practice Anesthesiology made its mark early on in the quest for patient safety. Eichhorn was a part of the converge…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34618/psn-pdf
    July 28, 2013 - National Survey on Consumers' Experiences With Patient Safety and Quality Information. July 28, 2013 Washington DC: Kaiser Family Foundation, Agency for Healthcare Research and Quality, Harvard School of Public Health; 2004. https://psnet.ahrq.gov/issue/national-survey-consumers-experiences-patient-safety-and-qual…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35563/psn-pdf
    June 08, 2010 - A comprehensive collaborative patient safety residency curriculum to address the ACGME core competencies. June 8, 2010 Singh R, Naughton B, Taylor JS, et al. A comprehensive collaborative patient safety residency curriculum to address the ACGME core competencies. Med Educ. 2005;39(12):1195-204. https://psnet.ahrq.…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44492/psn-pdf
    September 23, 2015 - Teamwork in Healthcare. September 23, 2015 Fam Syst Health. 2015;33(3):175-269. https://psnet.ahrq.gov/issue/teamwork-healthcare Teamwork is a key element of patient-centered care, but evidence regarding its use in the primary care environment is limited. Articles in this special issue examine the reasons for this…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44880/psn-pdf
    September 06, 2016 - Drug shortages forcing hard decisions on rationing treatments. September 6, 2016 Fink S. New York Times. January 29, 2016. https://psnet.ahrq.gov/issue/drug-shortages-forcing-hard-decisions-rationing-treatments Drug shortages have become a routine challenge in medicine. Reporting on the impact of medication short…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36882/psn-pdf
    February 24, 2011 - Resident perceptions of the impact of work hour limitations. February 24, 2011 Lin GA, Beck DC, Stewart AL, et al. Resident perceptions of the impact of work hour limitations. J Gen Intern Med. 2007;22(7):969-75. https://psnet.ahrq.gov/issue/resident-perceptions-impact-work-hour-limitations The investigators surv…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36610/psn-pdf
    January 14, 2011 - Prevent medication errors: a New Year's resolution: teaching patients about their medications. January 14, 2011 Polzien G. Prevent medication errors: A New Year's resolution: teaching patients about their medications. Home Healthc Nurse. 2007;25(1):59-62. https://psnet.ahrq.gov/issue/prevent-medication-errors-new-…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42025/psn-pdf
    February 06, 2013 - Medical malpractice: why is it so hard for doctors to apologize? February 6, 2013 Sanghavi D. https://psnet.ahrq.gov/issue/medical-malpractice-why-it-so-hard-doctors-apologize Discussing barriers to physician error disclosure, this article details how an apology-and-offer approach and analyzing claims data can im…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43411/psn-pdf
    October 01, 2014 - Analysis of medication errors in simulated pediatric resuscitation by residents. October 1, 2014 Porter E, Barcega B, Kim TY. Analysis of medication errors in simulated pediatric resuscitation by residents. West J Emerg Med. 2014;15(4):486-90. doi:10.5811/westjem.2014.2.17922. https://psnet.ahrq.gov/issue/analysis…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74733/psn-pdf
    February 02, 2022 - Prep, Stop, Block. February 2, 2022 RA-UK, the Faculty of Pain Medicine, RCoA Simulation and NHS Improvement https://psnet.ahrq.gov/issue/prep-stop-block Standardization is a common strategy for preventing practice deviations that can contribute to harm. This tool outlines a three-step process for minimizing the o…