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8761. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45642/psn-pdf
      November 09, 2016 - Rethinking medical ward quality. November 9, 2016 Pannick S, Wachter R, Vincent CA, et al. Rethinking medical ward quality. BMJ. 2016;355:i5417. doi:10.1136/bmj.i5417. https://psnet.ahrq.gov/issue/rethinking-medical-ward-quality Patient safety research and commentary often focus on specialized care processes rathe…

8762. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73396/psn-pdf
      June 16, 2021 - The impact of the built environment on patient falls in hospital rooms: an integrative review. June 16, 2021 Pati D, Valipoor S, Lorusso L, et al. The impact of the built environment on patient falls in hospital rooms: an integrative review. J Patient Saf. 2021;17(4):273-281. doi:10.1097/pts.0000000000000613. http…

8763. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61054/psn-pdf
      October 21, 2020 - The optimal use of telehealth to deliver safe patient care. October 21, 2020 Quick Safety. October 6, 2020;55:1-4. https://psnet.ahrq.gov/issue/optimal-use-telehealth-deliver-safe-patient-care Telehealth benefits, barriers, and challenges have become more apparent due to its increased use due to COVID-19 phys…

8764. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47018/psn-pdf
      June 13, 2018 - Opportunities to improve informed consent with AHRQ training modules. June 13, 2018 Shoemaker SJ, Brach C, Edwards A, et al. Opportunities to Improve Informed Consent with AHRQ Training Modules. Jt Comm J Qual Patient Saf. 2018;44(6):343-352. doi:10.1016/j.jcjq.2017.11.010. https://psnet.ahrq.gov/issue/opportuniti…

8765. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838031/psn-pdf
      September 13, 2022 - Addressing the Loss of Trust in Safety Culture. September 7, 2022 Philadelphia, PA: Building Trust and the ABIM Foundation; September 13, 2022.  https://psnet.ahrq.gov/issue/addressing-loss-trust-safety-culture Trust in patient safety processes encourages reporting of concerns, learning from error, and develop…

8766. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34570/psn-pdf
      March 07, 2005 - Measuring the Success of the Regional Medication Safety Program for Hospitals. March 7, 2005 Pelczarski K, Fricker M, Morris J. Philadelphia, PA: Health Care Improvement Foundation; 2005. https://psnet.ahrq.gov/issue/measuring-success-regional-medication-safety-program-hospitals The Regional Medication Safety Prog…

8767. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46736/psn-pdf
      December 17, 2018 - Back to basics: the Universal Protocol. December 17, 2018 Spruce L. Back to Basics: The Universal Protocol: 1.4 www.aornjournal.org/content/cme. AORN J. 2018;107(1):116-125. doi:10.1002/aorn.12002. https://psnet.ahrq.gov/issue/back-basics-universal-protocol Wrong-site, wrong-procedure, and wrong-patient errors are…

8768. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47997/psn-pdf
      May 08, 2019 - Blind spots in the science of safety. May 8, 2019 Bosk CL, Pedersen KZ. Blind spots in the science of safety. Lancet. 2019;393(10175):978-979. doi:10.1016/S0140-6736(19)30441-6. https://psnet.ahrq.gov/issue/blind-spots-science-safety Safety sciences offer methods to enhance processes and develop organizational cul…

8769. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43095/psn-pdf
      April 09, 2014 - Intravenous chemotherapy preparation errors: patient safety risks identified in a pan-Canadian exploratory study. April 9, 2014 White R, Cassano-Piché A, Fields A, et al. Intravenous chemotherapy preparation errors: patient safety risks identified in a pan-Canadian exploratory study. J Oncol Pharm Pract. 2014;20(1…

8770. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43527/psn-pdf
      September 24, 2014 - The morbidity and mortality conference in PICUs in the United States: a national survey. September 24, 2014 Cifra CL, Bembea MM, Fackler JC, et al. The morbidity and mortality conference in PICUs in the United States: a national survey. Crit Care Med. 2014;42(10):2252-7. doi:10.1097/CCM.0000000000000505. https://p…

8771. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867190/psn-pdf
      November 20, 2024 - Misdiagnosis is dangerous. Help your doctor get it right. November 20, 2024 Terry K. Misdiagnosis is dangerous. Help your doctor get it right. WebMD. November 11, 2024; https://psnet.ahrq.gov/issue/misdiagnosis-dangerous-help-your-doctor-get-it-right Patients are partners in health care and can inform actions to id…

8772. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46628/psn-pdf
      December 18, 2017 - Residency evaluations—where is the patient voice? December 18, 2017 Tummalapalli SL. Residency Evaluations-Where Is the Patient Voice? JAMA Intern Med. 2017;177(12):1722-1723. doi:10.1001/jamainternmed.2017.6029. https://psnet.ahrq.gov/issue/residency-evaluations-where-patient-voice Residents rarely receive feedba…

8773. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44594/psn-pdf
      March 15, 2016 - ICU attending handoff practices: results from a national survey of academic intensivists. March 15, 2016 Lane-Fall MB, Collard ML, Turnbull AE, et al. ICU Attending Handoff Practices: Results From a National Survey of Academic Intensivists. Crit Care Med. 2016;44(4):690-8. doi:10.1097/CCM.0000000000001470. https:/…

8774. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46401/psn-pdf
      September 13, 2017 - Understanding middle managers' influence in implementing patient safety culture. September 13, 2017 Gutberg J, Berta W. Understanding middle managers' influence in implementing patient safety culture. BMC Health Serv Res. 2017;17(1):582. doi:10.1186/s12913-017-2533-4. https://psnet.ahrq.gov/issue/understanding-mid…

8775. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46253/psn-pdf
      August 28, 2017 - Diagnostic stewardship—leveraging the laboratory to improve antimicrobial use. August 28, 2017 Morgan DJ, Malani P, Diekema DJ. Diagnostic Stewardship-Leveraging the Laboratory to Improve Antimicrobial Use. JAMA. 2017;318(7):607-608. doi:10.1001/jama.2017.8531. https://psnet.ahrq.gov/issue/diagnostic-stewardship-l…

8776. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46330/psn-pdf
      September 24, 2017 - Systemic error in radiology. September 24, 2017 Waite S, Scott JM, Legasto A, et al. Systemic Error in Radiology. AJR Am J Roentgenol. 2017;209(3):629- 639. doi:10.2214/AJR.16.17719. https://psnet.ahrq.gov/issue/systemic-error-radiology Radiology interpretation errors can contribute to diagnostic error. This comme…

8777. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46831/psn-pdf
      April 18, 2018 - Guideline Summary: Medication Safety. April 18, 2018 Guideline Summary: Medication Safety. AORN J. 2018;107(4):489-494. doi:10.1002/aorn.12096. https://psnet.ahrq.gov/issue/guideline-summary-medication-safety Perioperative medication errors can result in patient harm as well as emotional distress among clinical te…

8778. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44806/psn-pdf
      February 03, 2016 - Are Workarounds Ethical? Managing Moral Problems in Health Care Systems. February 3, 2016 Berlinger N. New York, NY: Oxford University Press; 2016. ISBN: 9780190269296. https://psnet.ahrq.gov/issue/are-workarounds-ethical-managing-moral-problems-health-care-systems Workarounds indicate process weaknesses that can …

8779. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60217/psn-pdf
      January 01, 2012 - MBRRACE-UK: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK. January 1, 2012 Oxford, UK: The National Perinatal Epidemiology Unit, University of Oxford. https://psnet.ahrq.gov/issue/mbrrace-uk-mothers-and-babies-reducing-risk-through-audits-and-confidential- enquiries-acro…

8780. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34697/psn-pdf
      December 08, 2010 - Sentinel events. In memory of Ben—a case study. December 8, 2010 Haas D. Sentinel events. In memory of Ben--a case study. Jt Comm Perspect. 1997;17(2):12-5. https://psnet.ahrq.gov/issue/sentinel-events-memory-ben-case-study Written from the perspective of a risk manager, the author tells the story of a medication a…