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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837980/psn-pdf
    March 21, 2024 - Diagnostic errors. March 21, 2024 Raffel K, Ranji S. UpToDate. February 8, 2024. https://psnet.ahrq.gov/issue/diagnostic-errors Diagnostic mistakes are common contributors to preventable patient harm. This review highlights primary areas of diagnostic error concerns (vascular events, infections, and cancers) …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41156/psn-pdf
    March 02, 2012 - The implementation of a perioperative checklist increases patients' perioperative safety and staff satisfaction. March 2, 2012 Böhmer AB, Wappler F, Tinschmann T, et al. The implementation of a perioperative checklist increases patients' perioperative safety and staff satisfaction. Acta Anaesthesiol Scand. 2012;56(…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38630/psn-pdf
    May 13, 2009 - Seasoned surgeons assessed in a laparoscopic surgical crisis. May 13, 2009 Powers K, Rehrig ST, Schwaitzberg SD, et al. Seasoned surgeons assessed in a laparoscopic surgical crisis. J Gastrointest Surg. 2009;13(5):994-1003. doi:10.1007/s11605-009-0802-1. https://psnet.ahrq.gov/issue/seasoned-surgeons-assessed-lapa…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40966/psn-pdf
    November 30, 2011 - Toward safer practice in otology: a report on 15 years of clinical negligence claims. November 30, 2011 Mathew R, Asimacopoulos E, Valentine P. Toward safer practice in otology: a report on 15 years of clinical negligence claims. Laryngoscope. 2011;121(10):2214-9. doi:10.1002/lary.22136. https://psnet.ahrq.gov/iss…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50577/psn-pdf
    October 23, 2019 - Medicare's Oversight of Ambulatory Surgery Centers Report. October 23, 2019 Washington, DC: Office of the Inspector General; September 2019. Report No. OEI-01-15-00400. https://psnet.ahrq.gov/issue/medicares-oversight-ambulatory-surgery-centers-report Ambulatory surgery centers (ASC) play an increasing role in com…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848384/psn-pdf
    May 03, 2023 - Roadmap to Health Care Safety for Massachusetts. May 3, 2023 Massachusetts Healthcare Safety and Quality Consortium. Boston, MA: Betsy Lehman Center for Patient Safety; April 2023. https://psnet.ahrq.gov/issue/roadmap-health-care-safety-massachusetts Collective engagement and focus are required to attain large sys…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45003/psn-pdf
    July 18, 2016 - Effect of surgical safety checklists on pediatric surgical complications in Ontario. July 18, 2016 O'Leary JD, Wijeysundera DN, Crawford MW. Effect of surgical safety checklists on pediatric surgical complications in Ontario. CMAJ. 2016;188(9):E191-E198. doi:10.1503/cmaj.151333. https://psnet.ahrq.gov/issue/effect…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40897/psn-pdf
    November 02, 2011 - Infrequent physician use of implantable cardioverter- defibrillators risks patient safety. November 2, 2011 Lyman S, Sedrakyan A, Do H, et al. Infrequent physician use of implantable cardioverter-defibrillators risks patient safety. Heart. 2011;97(20):1655-60. doi:10.1136/hrt.2011.226282. https://psnet.ahrq.gov/is…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39295/psn-pdf
    January 03, 2017 - The Veterans Affairs shift change physician-to-physician handoff project. January 3, 2017 Anderson J, Shroff D, Curtis A, et al. The Veterans Affairs shift change physician-to-physician handoff project. Jt Comm J Qual Patient Saf. 2010;36(2):62-71. https://psnet.ahrq.gov/issue/veterans-affairs-shift-change-physici…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47829/psn-pdf
    March 27, 2019 - The impact of internal service quality on preventable adverse events in hospitals. March 27, 2019 Zheng S, Tucker AL, Ren ZJ, et al. The Impact of Internal Service Quality on Preventable Adverse Events in Hospitals. Production Operations Manag. 2017;27(12):2201-2212. doi:10.1111/poms.12758. https://psnet.ahrq.gov/…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46885/psn-pdf
    March 20, 2018 - Opioid prescribing patterns and complications in the dermatology Medicare population. March 20, 2018 Cao S, Karmouta R, Li DG, et al. Opioid Prescribing Patterns and Complications in the Dermatology Medicare Population. JAMA Dermatol. 2018;154(3):317-322. doi:10.1001/jamadermatol.2017.5835. https://psnet.ahrq.gov/…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836720/psn-pdf
    March 09, 2022 - Reliability, uncertainty and the management of error: new perspectives in the COVID-19 era. March 9, 2022 Schulman PR. Reliability, uncertainty and the management of error: new perspectives in the COVID?19 era. J Contingencies Crisis Manage. 2022;30(1):92-101. doi:10.1111/1468-5973.12356. https://psnet.ahrq.gov/is…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73861/psn-pdf
    September 22, 2021 - Bringing the clinical laboratory into the strategy to advance diagnostic excellence. September 22, 2021 Lubin IM, Astles J R, Shahangian S, et al. Bringing the clinical laboratory into the strategy to advance diagnostic excellence. Diagnosis (Berl). 2021;8(3):281-294. doi:10.1515/dx-2020-0119. https://psnet.ahrq.g…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34930/psn-pdf
    April 06, 2011 - "Going solid": a model of system dynamics and consequences for patient safety. April 6, 2011 Cook R, Rasmussen J. "Going solid": a model of system dynamics and consequences for patient safety. Qual Saf Health Care. 2005;14(2):130-4. https://psnet.ahrq.gov/issue/going-solid-model-system-dynamics-and-consequences-pa…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867451/psn-pdf
    January 21, 2025 - Engineering Safety into Practice through Implementation of the EHR SAFER Guides. January 8, 2025 National Action Alliance for Patient and Workforce Safety. Engineering Safety into Practice through Implementation of the EHR SAFER Guides. January 21, 2025, 12:00 - 1:00 PM (eastern). https://psnet.ahrq.gov/issue/engi…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837747/psn-pdf
    July 27, 2022 - Measure Dx: A Resource to Identify, Analyze, and Learn from Diagnostic Safety Events. July 27, 2022 Rockville, MD: Agency for Healthcare Research and Quality; July 2022.  AHRQ Publication No. 22- 0038. https://psnet.ahrq.gov/issue/measure-dx-resource-identify-analyze-and-learn-diagnostic-safety-events Diagno…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72585/psn-pdf
    December 16, 2020 - Think health care workers are tested often for the Coronavirus? Think again. December 16, 2020 Wamsley L. National Public Radio and WBUR. December 7, 2020. https://psnet.ahrq.gov/issue/think-health-care-workers-are-tested-often-coronavirus-think-again Testing for COVID-19 is a core public safety strategy for …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60696/psn-pdf
    July 15, 2020 - Culture as a Cure: Assessments of Patient Safety Culture in OECD Countries. July 15, 2020 de Bienassisi K, Kristensenii S, Burtscheri M, et al for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 119. https://psnet.ahrq.gov/…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60897/psn-pdf
    January 01, 2022 - Association between surgeon technical skills and patient outcomes. September 9, 2020 Stulberg JJ, Huang R, Kreutzer L, et al. Association Between Surgeon Technical Skills and Patient Outcomes. JAMA Surg. 2022;157(3):219-220. doi:10.1001/jamasurg.2020.3007. https://psnet.ahrq.gov/issue/association-between-surgeon-t…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47289/psn-pdf
    October 24, 2018 - ASHP guidelines on managing drug product shortages. October 24, 2018 Fox ER, McLaughlin MM. ASHP guidelines on managing drug product shortages. Am J Health Syst Pharm. 2018;75(21):1742-1750. doi:10.2146/ajhp180441. https://psnet.ahrq.gov/issue/ashp-guidelines-managing-drug-product-shortages Drug shortages are a pe…

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