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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60975/psn-pdf
    September 30, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction. September 30, 2020 Zwaan L, Staal J. Rockville, MD: Agency for Healthcare Research and Quality; September 2020. AHRQ Publication No. 20-0040-3-EF. https://psnet.ahrq.gov/issue/evidence-use-clinical-reasoning-checklists-diagnostic…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45160/psn-pdf
    May 18, 2016 - Clues to better health care from old malpractice lawsuits. May 18, 2016 Landro L. https://psnet.ahrq.gov/issue/clues-better-health-care-old-malpractice-lawsuits Closed claims have been considered a source for adverse event data for years, and recently such data has been utilized to inform safety improvement work. …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43563/psn-pdf
    November 17, 2014 - Creating spaces in intensive care for safe communication: a video-reflexive ethnographic study. November 17, 2014 Hor S-Y, Iedema R, Manias E. Creating spaces in intensive care for safe communication: a video-reflexive ethnographic study. BMJ Qual Saf. 2014;23(12):1007-13. doi:10.1136/bmjqs-2014-002835. https://ps…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42159/psn-pdf
    March 04, 2015 - Peer review comments augment diagnostic error characterization and departmental quality assurance: 1- year experience from a children's hospital. March 4, 2015 Iyer RS, Swanson JO, Otto RK, et al. Peer review comments augment diagnostic error characterization and departmental quality assurance: 1-year experience f…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33934/psn-pdf
    March 02, 2011 - A hospitalization from hell: a patient's perspective on quality. March 2, 2011 Cleary PD. A hospitalization from hell: a patient's perspective on quality. Ann Intern Med. 2003;138(1):33- 39. https://psnet.ahrq.gov/issue/hospitalization-hell-patients-perspective-quality The author shares the unique perspectives of…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45949/psn-pdf
    July 11, 2017 - Beyond medication reconciliation: the correct medication list. July 11, 2017 Rose AJ, Fischer SH, Paasche-Orlow MK. Beyond Medication Reconciliation: The Correct Medication List. JAMA. 2017;317(20):2057-2058. doi:10.1001/jama.2017.4628. https://psnet.ahrq.gov/issue/beyond-medication-reconciliation-correct-medicati…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/864383/psn-pdf
    March 13, 2024 - Cyberattack on UnitedHealth still impacting prescription access: "These are threats to life". March 13, 2024 Sganga N, Triay A. CBS Evening News. February 29, 2024. https://psnet.ahrq.gov/issue/cyberattack-unitedhealth-still-impacting-prescription-access-these-are-threats- life As health care becomes more technol…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855002/psn-pdf
    November 01, 2023 - Temporarily holding medication orders safely in order to prevent patient harm. November 1, 2023 ISMP Medication Safety Alert! Acute care edition. October 19, 2023;28(21):1-4. https://psnet.ahrq.gov/issue/temporarily-holding-medication-orders-safely-order-prevent-patient-harm Process disconnects can cause administr…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46143/psn-pdf
    June 14, 2017 - Report of the Announced Inspection of Medication Safety at the Midland Regional Hospital Tullamore, County Offaly. June 14, 2017 Dublin, Ireland: Health Information and Quality Authority; May 2017. https://psnet.ahrq.gov/issue/report-announced-inspection-medication-safety-midland-regional-hospital- tullamore-coun…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45749/psn-pdf
    January 11, 2017 - Instrument count sheets and set reviews as patient safety tools. January 11, 2017 Spear J. Instrument Count Sheets and Set Reviews as Patient Safety Tools. AORN J. 2016;104(6):588- 592. doi:10.1016/j.aorn.2016.10.007. https://psnet.ahrq.gov/issue/instrument-count-sheets-and-set-reviews-patient-safety-tools Inaccu…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44413/psn-pdf
    October 07, 2015 - Improving transitions of care for patients on warfarin: the Safe Transitions Anticoagulation Report. October 7, 2015 Dunn AS, Shetreat-Klein A, Berman J, et al. Improving transitions of care for patients on warfarin: The safe transitions anticoagulation report. J Hosp Med. 2015;10(9):615-8. doi:10.1002/jhm.2393. h…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838083/psn-pdf
    September 14, 2022 - A pause in pediatrics: implementation of a pediatric diagnostic time-out. September 14, 2022 Yale SC, Cohen SS, Kliegman RM, et al. A pause in pediatrics: implementation of a pediatric diagnostic time-out. Diagnosis (Berl). 2022;9(3):348-351. doi:10.1515/dx-2022-0010. https://psnet.ahrq.gov/issue/pause-pediatrics-…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837077/psn-pdf
    May 11, 2022 - At US hospitals, a drug mix-up is just a few keystrokes away. May 11, 2022 Kelman B. Kaiser Health News. April 29, 2022. https://psnet.ahrq.gov/issue/us-hospitals-drug-mix-just-few-keystrokes-away Technological solutions harbor unique risks that can result in patient harm. This article shares a response to report…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60750/psn-pdf
    August 06, 2020 - Missed breast cancer: effects of subconscious bias and lesion characteristics. August 6, 2020 Lamb LR, Mohallem Fonseca M, Verma R, et al. Missed breast cancer: effects of subconscious bias and lesion characteristics. RadioGraphics. 2020;40(4):941-960. doi:10.1148/rg.2020190090. https://psnet.ahrq.gov/issue/missed…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44474/psn-pdf
    September 24, 2016 - Interruptions in the wild: development of a sociotechnical systems model of interruptions in the emergency department through a systematic review. September 24, 2016 Werner N, Holden RJ. Interruptions in the wild: Development of a sociotechnical systems model of interruptions in the emergency department through a …

  16. Exhibit 6.9. Lean Project Roles Mapped to Functional Roles | Agency for Healthcare Research and Quality

    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit6-9.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 6.9. Lean Project Roles Mapped to Functional Roles Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Healthcare …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866820/psn-pdf
    September 25, 2024 - Interrogating and uprooting systemic racism in the emergency department. September 25, 2024 Sangal RB, Khidir H, Agarwal AK. Interrogating and uprooting systemic racism in the emergency department. JAMA Health Forum. 2024;5(8):e242347. doi:10.1001/jamahealthforum.2024.2347. https://psnet.ahrq.gov/issue/interrogati…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849606/psn-pdf
    May 31, 2023 - The Patient Safety Adoption Framework: a practical framework to bridge the know-do gap. May 31, 2023 Moyal-Smith R, Margo J, Maloney FL, et al. J Patient Saf. 2023;19(4):243-248. https://psnet.ahrq.gov/issue/patient-safety-adoption-framework-practical-framework-bridge-know-do-gap Individual, team, and organization…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43347/psn-pdf
    September 03, 2014 - POPI (Pediatrics: Omission of Prescriptions and Inappropriate prescriptions): development of a tool to identify inappropriate prescribing. September 3, 2014 Prot-Labarthe S, Weil T, Angoulvant F, et al. POPI (Pediatrics: Omission of Prescriptions and Inappropriate prescriptions): development of a tool to identify …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866649/psn-pdf
    September 04, 2024 - AI as an ecosystem — ensuring generative AI is safe and effective. September 4, 2024 Coiera E, Fraile-Navarro D. AI as an ecosystem — ensuring generative AI is safe and effective. NEJM AI. 2024;1(9):AIp2400611. doi:10.1056/aip2400611. https://psnet.ahrq.gov/issue/ai-ecosystem-ensuring-generative-ai-safe-and-effect…
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