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  1. 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…

  2. 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…

  3. 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 …

  4. 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…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44830/psn-pdf
    January 01, 2019 - Tune-in and time-out: toward surgeon-led prevention of "never" events. February 17, 2016 Jones N. Tune-In and Time-Out: Toward Surgeon-Led Prevention of "Never" Events. J Patient Saf. 2019;15(4):e36-e39. doi:10.1097/PTS.0000000000000259. https://psnet.ahrq.gov/issue/tune-and-time-out-toward-surgeon-led-prevention-…

  6. Exhibit 1.11. Project Team Composition—Bed Flow Project at Each Hospital | Agency for Healthcare Research and Quality

    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit1-11.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 1.11. Project Team Composition—Bed Flow Project at Each Hospital Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43395/psn-pdf
    July 30, 2014 - The current and ideal state of anatomic pathology patient safety. July 30, 2014 Raab SS. The current and ideal state of anatomic pathology patient safety. MLO Med Lab Obs. 2014;46(6):8-10. https://psnet.ahrq.gov/issue/current-and-ideal-state-anatomic-pathology-patient-safety This commentary illustrates the proces…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43789/psn-pdf
    August 05, 2015 - Do cell phones belong in the operating room? August 5, 2015 Luthra S. Kaiser Health News. July 14, 2015. https://psnet.ahrq.gov/issue/do-cell-phones-belong-operating-room Distractions can lead to care and process omissions. Reporting on the prevalence of mobile technology in the operating room and how it can hinde…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48169/psn-pdf
    July 24, 2019 - 50 Years of Inquiries in the National Health Service. July 24, 2019 Polit Q. 2019;90:177-342. https://psnet.ahrq.gov/issue/50-years-inquiries-national-health-service The National Health Service strategy of publishing their inquiries into systematic poor care in the health service is a model of transparency. Articl…

  10. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/worksheet.docx
    May 01, 2017 - AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership AHRQ Safety Program for Perinatal Care Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership Purpose: To enhance communication and shared problem solving between clinic…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39789/psn-pdf
    August 25, 2010 - Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections. August 25, 2010 Sawyer M, Weeks K, Goeschel CA, et al. Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections. Crit Care Med. 201…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46648/psn-pdf
    March 14, 2018 - Parenteral nutrition errors and potential errors reported over the past 10 years. March 14, 2018 Guenter P, Ayers P, Boullata JI, et al. Parenteral Nutrition Errors and Potential Errors Reported Over the Past 10 Years. Nutr Clin Pract. 2017;32(6):826-830. doi:10.1177/0884533617715868. https://psnet.ahrq.gov/issue/…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37259/psn-pdf
    March 23, 2011 - Using a survey of incident reporting and learning practices to improve organisational learning at a cancer care centre. March 23, 2011 Cooke DL, Dunscombe PB, Lee R. Using a survey of incident reporting and learning practices to improve organisational learning at a cancer care centre. Qual Saf Health Care. 2007;16…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836970/psn-pdf
    April 20, 2022 - ASHP Standard for Certification as a Center of Excellence in Medication-Use Safety and Pharmacy Practice. April 20, 2022 Am J Health Syst Pharm. 2022;79(7): 564-599. https://psnet.ahrq.gov/issue/ashp-standard-certification-center-excellence-medication-use-safety-and- pharmacy-practice Pharmacists have a central r…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44408/psn-pdf
    April 12, 2017 - Enhancing Surgical Performance: A Primer in Non- technical Skills. April 12, 2017 Flin R, Youngson GG, Yule S. Boca Raton, FL: CRC Press; 2015. ISBN: 9781482246322. https://psnet.ahrq.gov/issue/enhancing-surgical-performance-primer-non-technical-skills Non-technical skill development is gaining attention as a way …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36520/psn-pdf
    June 14, 2011 - Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. June 14, 2011 Braithwaite J, Westbrook MT, Mallock NA, et al. Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. Qual Saf Health…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45711/psn-pdf
    March 27, 2017 - Management of a patient with a latex allergy. March 27, 2017 Minami CA, Barnard C, Bilimoria KY. Management of a Patient With a Latex Allergy. JAMA. 2017;317(3):309-310. doi:10.1001/jama.2016.20034. https://psnet.ahrq.gov/issue/management-patient-latex-allergy This case analysis discusses the use of a latex cathet…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45682/psn-pdf
    November 01, 2017 - Changing smart pump vendors: lessons learned. November 1, 2017 Arthur KJ, Catlin AC, Quebe A, et al. Changing Smart Pump Vendors: Lessons Learned. Hosp Pharm. 2016;51(9):782-789. https://psnet.ahrq.gov/issue/changing-smart-pump-vendors-lessons-learned Changes in processes, devices, and technologies can increase ri…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73450/psn-pdf
    June 30, 2021 - Decision Making in Emergency Medicine: Biases, Errors and Solutions. June 30, 2021 Raz M, Pouryahya P, eds. Singapore; Springer Nature Singapore Pte Ltd; 2021. ISBN 9789811601422. https://psnet.ahrq.gov/issue/decision-making-emergency-medicine-biases-errors-and-solutions Decision making is vulnerable to huma…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43440/psn-pdf
    August 13, 2014 - Hospital Experiences Using Electronic Health Records to Support Medication Reconciliation. August 13, 2014 Grossman JM, Gourevitch R, Cross D. Washington, DC: National Institute for Health Care Reform; July 2014. NIHCR Research Brief No. 17. https://psnet.ahrq.gov/issue/hospital-experiences-using-electronic-health…
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