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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39256/psn-pdf
    November 14, 2011 - Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009. November 14, 2011 Oakbrook Terrace, IL: The Joint Commission; January 2010. https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and- safety-2009 America's hospitals continu…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42247/psn-pdf
    June 12, 2013 - A multicenter, multidisciplinary, high-alert medication collaborative to improve patient safety: the Singapore experience. June 12, 2013 Khoo AL, Teng M, Lim BP, et al. A multicenter, multidisciplinary, high-alert medication collaborative to improve patient safety: the Singapore experience. Jt Comm J Qual Patient …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60630/psn-pdf
    June 24, 2020 - Education is “predictably disappointing” and should never be relied upon alone to improve safety. June 24, 2020 ISMP Medication Safety Alert! Acute care edition. June 4, 2020;25(11):1-4. https://psnet.ahrq.gov/issue/education-predictably-disappointing-and-should-never-be-relied-upon-alone- improve-safety Interven…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73328/psn-pdf
    May 26, 2021 - Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia. May 26, 2021 Washington DC:  Department of Veterans Affairs. Office of Inspector General; May 11, 2021. Report No. 20-03593-140. https://psnet.ahrq.gov/issue/care-and-oversigh…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837041/psn-pdf
    May 04, 2022 - APSF endorsed statement on revising recommendations for patient monitoring during anesthesia. May 4, 2022 The APSF Committee on Technology. APSF Newsletter. 2022;37(1):7–8. https://psnet.ahrq.gov/issue/apsf-endorsed-statement-revising-recommendations-patient-monitoring-during- anesthesia Variation across sta…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34998/psn-pdf
    June 22, 2009 - Cause and effect analysis of closed claims in obstetrics and gynecology. June 22, 2009 White AA, Pichert JW, Bledsoe SH, et al. Cause and effect analysis of closed claims in obstetrics and gynecology. Obstet Gynecol. 2005;105(5 Pt 1):1031-1038. https://psnet.ahrq.gov/issue/cause-and-effect-analysis-closed-claims-o…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837855/psn-pdf
    August 17, 2022 - Patterns of error in interpretive pathology. August 17, 2022 Packer MDC, Ravinsky E, Azordegan N. Patterns of error in interpretive pathology. Am J Clin Pathol. 2022;157(5):767-773. doi:10.1093/ajcp/aqab190. https://psnet.ahrq.gov/issue/patterns-error-interpretive-pathology Studies have shown diagnostic discordanc…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38333/psn-pdf
    January 14, 2009 - Adverse Events in Hospitals: Overview of Key Issues. January 14, 2009 Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470. https://psnet.ahrq.gov/issue/adverse-events-hospitals-overview-key-issues The Tax Relief and Hea…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841488/psn-pdf
    December 14, 2022 - ASHP Guidelines on Preventing Diversion of Controlled Substances. December 14, 2022 Clark J, Fera T, Fortier CR, et al. ASHP Guidelines on Preventing Diversion of Controlled Substances. Am J Health Syst Pharm. 2022;79(24):2279-2306. doi:10.1093/ajhp/zxac246. https://psnet.ahrq.gov/issue/ashp-guidelines-preventing-…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849615/psn-pdf
    May 31, 2023 - Clinical Investigation Booking Systems Failures: Written Communications in Community Languages. May 31, 2023 Farnborough, UK: Healthcare Safety Investigation Branch; April 2023. https://psnet.ahrq.gov/issue/clinical-investigation-booking-systems-failures-written-communications- community-languages Gaps in patient…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48134/psn-pdf
    August 14, 2019 - Root cause analysis for hospital-acquired pressure injury. August 14, 2019 Black JM. Root cause analysis for hospital-acquired pressure injury. J Wound Ostomy Continence Nurs. 2019;46(4):298-304. doi:10.1097/WON.0000000000000546. https://psnet.ahrq.gov/issue/root-cause-analysis-hospital-acquired-pressure-injury Pr…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46238/psn-pdf
    November 08, 2017 - Workarounds are routinely used by nurses—but are they ethical? November 8, 2017 Berlinger N. Workarounds Are Routinely Used by Nurses-But Are They Ethical? Am J Nurs. 2017;117(10):53-55. doi:10.1097/01.NAJ.0000525875.82101.b7. https://psnet.ahrq.gov/issue/workarounds-are-routinely-used-nurses-are-they-ethical Wor…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867020/psn-pdf
    October 23, 2024 - What can we learn from coroners’ reports on preventable deaths? October 23, 2024 Jeraj S. What can we learn from coroners’ reports on preventable deaths? BMJ. 2024;386:q1943. https://psnet.ahrq.gov/issue/what-can-we-learn-coroners-reports-preventable-deaths Analysis of system failure is only the beginning of the i…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46670/psn-pdf
    December 18, 2017 - A narrative review of the safety concerns of deprescribing in older adults and strategies to mitigate potential harms. December 18, 2017 Reeve E, Moriarty F, Nahas R, et al. A narrative review of the safety concerns of deprescribing in older adults and strategies to mitigate potential harms. Expert Opin Drug Saf. 2…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46311/psn-pdf
    August 23, 2017 - Swimming against the tide: primary care physicians' views on deprescribing in everyday practice. August 23, 2017 Wallis KA, Andrews A, Henderson M. Swimming Against the Tide: Primary Care Physicians’ Views on Deprescribing in Everyday Practice. Ann Fam Med. 2017;15(4):341-346. doi:10.1370/afm.2094. https://psnet.a…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39349/psn-pdf
    March 23, 2011 - Promoting patient safety through prospective risk identification: example from peri-operative care. March 23, 2011 Smith AF, Boult M, Woods I, et al. Promoting patient safety through prospective risk identification: example from peri-operative care. Qual Saf Health Care. 2010;19(1):69-73. doi:10.1136/qshc.2008.0280…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38070/psn-pdf
    March 10, 2011 - Can surveillance systems identify and avert adverse drug events? A prospective evaluation of a commercial application. March 10, 2011 Jha AK, Laguette J, Seger AC, et al. Can surveillance systems identify and avert adverse drug events? A prospective evaluation of a commercial application. J Am Med Inform Assoc. 20…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43854/psn-pdf
    February 11, 2015 - Medicare’s Oversight of Compounded Pharmaceuticals Used in Hospitals. February 11, 2015 Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 2015. Report No. OEI-01-13-00400. https://psnet.ahrq.gov/issue/medicares-oversight-compounded-pharmaceuticals-use…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42996/psn-pdf
    March 19, 2014 - The "physician-led chart audit": engaging providers in fortifying a culture of safety. March 19, 2014 Gitkind MJ, Perla RJ, Manno M, et al. The "physician-led chart audit: " engaging providers in fortifying a culture of safety. J Patient Saf. 2014;10(1):72-9. doi:10.1097/PTS.0000000000000057. https://psnet.ahrq.go…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35721/psn-pdf
    March 28, 2011 - Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology ward. March 28, 2011 van Tilburg CM, Leistikow IP, Rademaker CMA, et al. Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology ward. Qual Saf Health Care. 2006;15(1…
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