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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854266/psn-pdf
    October 04, 2023 - Smart Healthcare Safety. October 4, 2023 Plymouth Meeting PA, ECRI. 2019-2023. https://psnet.ahrq.gov/issue/smart-healthcare-safety A wide variety of considerations must converge to inform an understanding of system vulnerabilities and the application of strategies to address them. This series of webinars covers a…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43015/psn-pdf
    May 29, 2014 - Team-training in healthcare: a narrative synthesis of the literature. May 29, 2014 Weaver SJ, Dy SM, Rosen MA. Team-training in healthcare: a narrative synthesis of the literature. BMJ Qual Saf. 2014;23(5):359-72. doi:10.1136/bmjqs-2013-001848. https://psnet.ahrq.gov/issue/team-training-healthcare-narrative-synthe…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866359/psn-pdf
    June 01, 2022 - Diagnostic Safety Toolkit. June 1, 2022 Diagnostic Safety Toolkit. https://psnet.ahrq.gov/issue/diagnostic-safety-toolkit-0 Effective communication is critical as patients shift from one level of care to another as their diagnosis evolves. This toolkit is designed to help academic medical centers initiate conversa…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/856641/psn-pdf
    January 01, 2009 - WebAIRS Anesthesia Incident Reporting System. January 1, 2009 Australian and New Zealand Tripartite Anaesthetic Data Committee. https://psnet.ahrq.gov/issue/webairs-anesthesia-incident-reporting-system Reporting errors in anesthesiology practice can motivate and inform safety improvement work. This website serves …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47696/psn-pdf
    February 22, 2019 - Operating room fires. February 22, 2019 Jones TS, Black IH, Robinson TN, et al. Operating Room Fires. Anesthesiology. 2019;130(3):492-501. doi:10.1097/ALN.0000000000002598. https://psnet.ahrq.gov/issue/operating-room-fires Surgical fires, though uncommon, can result in serious harm. This review highlights three co…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38885/psn-pdf
    August 19, 2009 - Patient safety: Part II. Opportunities for improvement in patient safety. August 19, 2009 Elston DM, Stratman E, Johnson-Jahangir H, et al. Patient safety: Part II. Opportunities for improvement in patient safety. J Am Acad Dermatol. 2009;61(2):193-205; quiz 206. doi:10.1016/j.jaad.2009.04.055. https://psnet.ahrq.…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47144/psn-pdf
    June 13, 2018 - Canadian Anesthesia Incident Reporting System. June 13, 2018 Canadian Anaesthesiologists Society. https://psnet.ahrq.gov/issue/canadian-anesthesia-incident-reporting-system Reporting mistakes in anesthesiology practice can motivate and inform error reduction work. This website provides a secure tool for submitting…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38305/psn-pdf
    January 15, 2009 - High-alert medications in the pediatric intensive care unit. January 15, 2009 Franke HA, Woods D, Holl JL. High-alert medications in the pediatric intensive care unit. Pediatr Crit Care Med. 2009;10(1):85-90. doi:10.1097/PCC.0b013e3181936ff8. https://psnet.ahrq.gov/issue/high-alert-medications-pediatric-intensive-c…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46557/psn-pdf
    November 22, 2017 - Safe handover. November 22, 2017 Merten H, van Galen LS, Wagner C. Safe handover. BMJ. 2017;359:j4328. doi:10.1136/bmj.j4328. https://psnet.ahrq.gov/issue/safe-handover Patient handovers between clinical teams are a common point of information exchange that can be challenging to perform due to interruptions, produ…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45086/psn-pdf
    July 02, 2019 - Half-life of a printed handoff document. July 2, 2019 Rosenbluth G, Jacolbia R, Milev D, et al. Half-life of a printed handoff document. BMJ Qual Saf. 2016;25(5):324-8. doi:10.1136/bmjqs-2015-004585. https://psnet.ahrq.gov/issue/half-life-printed-handoff-document Despite advances in handoff practices, printed sign…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44502/psn-pdf
    May 07, 2018 - Draft Guidelines for the Safe Communication of Electronic Medication Information. May 7, 2018 Institute for Safe Medication Practices. Acute Care Edition. August 27, 2015;2;1-3,6. https://psnet.ahrq.gov/issue/draft-guidelines-safe-communication-electronic-medication-information How electronic medication-related in…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38561/psn-pdf
    April 15, 2009 - Health-Care–Associated Infections in Hospitals: Continuing Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on These Infections. April 15, 2009 Subcommittee on Health Care, Committee on Finance, US Senate, Government Accountability Office, GAO-09-516T (March 18, 2009) https://psnet.…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35391/psn-pdf
    April 06, 2011 - Effectiveness of a graduate medical education program for improving medical event reporting attitude and behavior.   April 6, 2011 Coyle YM, Mercer SQ, Murphy-Cullen CL, et al. Effectiveness of a graduate medical education program for improving medical event reporting attitude and behavior. Qual Saf Health Care. 2…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39369/psn-pdf
    March 17, 2010 - Paediatric nurses' understanding of the process and procedure of double-checking medications. March 17, 2010 Dickinson A, McCall E, Twomey B, et al. Paediatric nurses' understanding of the process and procedure of double-checking medications. J Clin Nurs. 2010;19(5-6). doi:10.1111/j.1365-2702.2009.03130.x. https:/…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35657/psn-pdf
    July 05, 2013 - Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety. July 5, 2013 Casey MM, Moscovice I, Davidson G. Minneapolis, MN: Upper Midwest Rural Health Research Center; 2005. https://psnet.ahrq.gov/issue/pharmacist-staffing-and-use-technology-small-rural-hospitals-im…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43010/psn-pdf
    March 19, 2014 - Why pediatricians fail to diagnose hypertension: a multicenter survey. March 19, 2014 Bijlsma MW, Blufpand HN, Kaspers GJL, et al. Why pediatricians fail to diagnose hypertension: a multicenter survey. J Pediatr. 2014;164(1):173-177.e7. doi:10.1016/j.jpeds.2013.08.066. https://psnet.ahrq.gov/issue/why-pediatrician…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45006/psn-pdf
    April 06, 2016 - Quality and Patient Safety. April 6, 2016 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/quality-and-patient-safety The Agency for Healthcare Research and Quality has provided access to patient safety research, information, and tools for nearly two decades. This website offers a wide rang…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46233/psn-pdf
    September 24, 2017 - Cutting-edge efforts in surgical patient safety. September 24, 2017 Varghese TK, Ghaferi AA. Cutting-edge Efforts in Surgical Patient Safety. JAMA Surg. 2017;152(8):719- 720. doi:10.1001/jamasurg.2017.0858. https://psnet.ahrq.gov/issue/cutting-edge-efforts-surgical-patient-safety Implementation science examines me…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38339/psn-pdf
    January 31, 2011 - Physician autonomy and informed decision making: finding the balance for patient safety and quality. January 31, 2011 Mathews SC, Pronovost P. Physician autonomy and informed decision making: finding the balance for patient safety and quality. JAMA. 2008;300(24):2913-5. doi:10.1001/jama.2008.846. https://psnet.ahr…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37938/psn-pdf
    July 23, 2008 - An integrative review of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections. July 23, 2008 Backman C, Zoutman DE, Marck PB. An integrative review of the current evidence on the relationship between hand hygiene interventions and the in…

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