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8701. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838192/psn-pdf
      September 28, 2022 - When medical error becomes personal, activism becomes painful. September 28, 2022 Millenson M. Forbes. September 16, 2022. https://psnet.ahrq.gov/issue/when-medical-error-becomes-personal-activism-becomes-painful Unnecessary medication infusions indicate weaknesses in medication service processes. While no harm w…

8702. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74093/psn-pdf
      November 17, 2021 - Prevent errors during emergency use of hypertonic sodium chloride solutions. November 17, 2021 ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4. https://psnet.ahrq.gov/issue/prevent-errors-during-emergency-use-hypertonic-sodium-chloride-solutions Delays in diagnosis and treatment duri…

8703. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42019/psn-pdf
      December 29, 2014 - Can incident reporting improve safety? Healthcare practitioners' views of the effectiveness of incident reporting. December 29, 2014 Anderson JE, Kodate N, Walters R, et al. Can incident reporting improve safety? Healthcare practitioners' views of the effectiveness of incident reporting. Int J Qual Health Care. 20…

8704. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842779/psn-pdf
      January 12, 2011 - Resilience Engineering in Practice: a Guidebook. January 12, 2011 Hollnagel E, Parie?s J, Woods DD et al eds. Farnham UK; Ashgate, 2011. ISBN: 9781472420749 https://psnet.ahrq.gov/issue/resilience-engineering-practice-guidebook Safety-critical industries rely on organizational aptitude to respond to disr…

8705. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47885/psn-pdf
      May 01, 2019 - Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital. May 1, 2019 Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236. https://psnet.ahrq.gov/issue/deny-dismiss-dehumanise-what-happened-when-i-went-hospital Patient stories offer important insights regarding the impact m…

8706. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47960/psn-pdf
      May 15, 2019 - A systematic review of clinical decision support systems for clinical oncology practice. May 15, 2019 Pawloski PA, Brooks GA, Nielsen ME, et al. A Systematic Review of Clinical Decision Support Systems for Clinical Oncology Practice. J Natl Compr Canc Netw. 2019;17(4):331-338. doi:10.6004/jnccn.2018.7104. https://…

8707. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45633/psn-pdf
      December 21, 2016 - Lost in translation: medication labeling for immigrant families. December 21, 2016 Smith MCJ, Yin S, Sanders LM. Lost in translation: Medication labeling for immigrant families. J Am Pharm Assoc (2003). 2016;56(6):677-679. doi:10.1016/j.japh.2016.07.002. https://psnet.ahrq.gov/issue/lost-translation-medication-lab…

8708. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34648/psn-pdf
      April 21, 2015 - Gaps in the continuity of care and progress on patient safety. April 21, 2015 Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ. 2000;320(7237):791-4. https://psnet.ahrq.gov/issue/gaps-continuity-care-and-progress-patient-safety This commentary discusses the concept o…

8709. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47081/psn-pdf
      September 02, 2018 - Beyond Dr. Google: the evidence on consumer-facing digital tools for diagnosis. September 2, 2018 Millenson ML, Baldwin JL, Zipperer L, et al. Beyond Dr. Google: the evidence on consumer-facing digital tools for diagnosis. Diagnosis (Berl). 2018;5(3):95-105. doi:10.1515/dx-2018-0009. https://psnet.ahrq.gov/issue/b…

8710. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866358/psn-pdf
      July 24, 2024 - To improve health care, focus on fixing systems — not people. July 24, 2024 Mate KS, Clark J, Salvon-Harman J. To improve health care, focus on fixing systems — not people. Harvard Business Review. July 12, 2024; https://psnet.ahrq.gov/issue/improve-health-care-focus-fixing-systems-not-people While a focus on the…

8711. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43232/psn-pdf
      June 04, 2014 - Standardization in patient safety: the WHO High 5s project. June 4, 2014 Leotsakos A, Zheng H, Croteau R, et al. Standardization in patient safety: the WHO High 5s project. Int J Qual Health Care. 2014;26(2):109-16. doi:10.1093/intqhc/mzu010. https://psnet.ahrq.gov/issue/standardization-patient-safety-who-high-5s-…

8712. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73973/psn-pdf
      October 13, 2021 - Agency information collection activities: National Healthcare Safety Network (NHSN); comment request. October 13, 2021 Zirger JM, Centers for Disease Control and Prevention. Fed Register. September 27, 2021;86:53309-53312. https://psnet.ahrq.gov/issue/agency-information-collection-activities-national-healthca…

8713. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47961/psn-pdf
      January 01, 2021 - Patient and physician experience with interhospital transfer: a qualitative study. June 2, 2019 Mueller SK, Shannon E, Dalal A, et al. Patient and Physician Experience with Interhospital Transfer: A Qualitative Study. J Patient Saf. 2021;17(8):e752-e757. doi:10.1097/PTS.0000000000000501. https://psnet.ahrq.gov/iss…

8714. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/864385/psn-pdf
      April 05, 2024 - Common Formats for Patient Safety Data Collection. March 13, 2024 Agency for Healthcare Research and Quality. Fed Register. Mar 6, 2024;89(45);15992. https://psnet.ahrq.gov/issue/common-formats-patient-safety-data-collection A standard system for voluntary reporting to patient safety organizations improves measurem…

8715. COVID-19 Identification & Prevention series | Agency for Healthcare Research and Quality
      www.ahrq.gov/nursing-home/learning-modules/covid-id-prevention.html
      December 01, 2022 - COVID-19 Identification & Prevention series This series of three learning modules focuses on identifying the signs and symptoms of COVID-19, knowing when and how to report signs and symptoms of COVID-19, and remembering to maintain infection prevention processes. Module 1: COVID-19 Identification and Preventi…

8716. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/764410/psn-pdf
      March 02, 2022 - Five strategies for clinicians to advance diagnostic excellence. March 2, 2022 Singh H, Connor DM, Dhaliwal G. Five strategies for clinicians to advance diagnostic excellence. BMJ. 2022;376:e068044. doi:10.1136/bmj-2021-068044. https://psnet.ahrq.gov/issue/five-strategies-clinicians-advance-diagnostic-excellence …

8717. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46524/psn-pdf
      October 18, 2017 - Pressure Injury Prevention in Hospitals Training Program. October 18, 2017 Rockville, MD: Agency for Healthcare Research and Quality; September 2017. https://psnet.ahrq.gov/issue/pressure-injury-prevention-hospitals-training-program Pressure ulcers are a common hospital-acquired condition that can lead to patient h…

8718. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36027/psn-pdf
      March 28, 2011 - Medical injuries among hospitalized children. March 28, 2011 Meurer JR, Yang H, Guse CE, et al. Medical injuries among hospitalized children. Qual Saf Health Care. 2006;15(3):202-7. https://psnet.ahrq.gov/issue/medical-injuries-among-hospitalized-children This AHRQ–funded study applied new screening criteria to ca…

8719. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46240/psn-pdf
      June 21, 2017 - Implementation of a modified bedside handoff for a postpartum unit. June 21, 2017 Wollenhaup CA, Stevenson EL, Thompson J, et al. Implementation of a Modified Bedside Handoff for a Postpartum Unit. J Nurs Admin. 2017;47(6):320-326. doi:10.1097/NNA.0000000000000487. https://psnet.ahrq.gov/issue/implementation-modif…

8720. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34765/psn-pdf
      January 04, 2017 - The Fifth Discipline: The Art & Practice of The Learning Organization. Revised & Updated Edition. January 4, 2017 Senge PM. New York, NY: Currency Doubleday; 2009. ISBN: 9780385517256. https://psnet.ahrq.gov/issue/fifth-discipline-art-practice-learning-organization-revised-updated-edition Senge’s seminal and oft-r…