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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46972/psn-pdf
    March 28, 2018 - SOPS Health Information Technology Patient Safety Supplemental Item Set for the Hospital Survey. March 28, 2018 Rockville, MD: Agency for Healthcare Research and Quality; March 2018. https://psnet.ahrq.gov/issue/sops-health-information-technology-patient-safety-supplemental-item-set- hospital-survey Organizationa…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838082/psn-pdf
    September 14, 2022 - Organizational factors that promote error reporting in healthcare: a scoping review. September 14, 2022 Wawersik D, Palaganas J. Organizational factors that promote error reporting in healthcare: a scoping review. J Healthc Manag. 2022;67(4):283-301. doi:10.1097/jhm-d-21-00166. https://psnet.ahrq.gov/issue/organiz…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845076/psn-pdf
    February 22, 2023 - Advancing diagnostic equity through clinician engagement, community partnerships, and connected care. February 22, 2023 Giardina TD, Woodard LCD, Singh H. Advancing diagnostic equity through clinician engagement, community partnerships, and connected care. J Gen Intern Med. 2023;38(5):1293-1295. doi:10.1007/s1160…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74697/psn-pdf
    January 26, 2022 - The effect of medication reconciliation via a patient portal on medication discrepancies: a randomized noninferiority study. January 26, 2022 Ebbens MM, Gombert-Handoko KB, Wesselink EJ, et al. The effect of medication reconciliation via a patient portal on medication discrepancies: a randomized noninferiority stu…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845350/psn-pdf
    March 01, 2023 - Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists. March 1, 2023 Kelly FE, Frerk C, Bailey CR, et al. Implementing human factors in anaesthesia: guidance for clinicians, departments and h…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47564/psn-pdf
    December 05, 2018 - Challenges and opportunities for improving patient safety through human factors and systems engineering. December 5, 2018 Carayon P, Wooldridge A, Hose B-Z, et al. Challenges And Opportunities For Improving Patient Safety Through Human Factors And Systems Engineering. Health Aff (Millwood). 2018;37(11):1862-1869. …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848085/psn-pdf
    April 26, 2023 - Understanding complexity in a safety critical setting: a systems approach to medication administration. April 26, 2023 Stevens EL, Hulme A, Goode N, et al. Understanding complexity in a safety critical setting: a systems approach to medication administration. Appl Ergon. 2023;110:104000. doi:10.1016/j.apergo.2023.1…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74273/psn-pdf
    January 19, 2022 - Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints. January 19, 2022 Washington, DC: United States Government Accountability Office; November 30, 2021. Publication GAO- 22-105142. https://psnet.ahrq.gov/issue/community-living-centers-va-needs-strengthen-its-approach-ad…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34657/psn-pdf
    June 14, 2011 - Multidisciplinary approaches to reducing error and risk in a patient care setting. June 14, 2011 Connor M, Ponte PR, Conway JB. Multidisciplinary approaches to reducing error and risk in a patient care setting. Crit Care Nurs Clin North Am. 2002;14(4):359-67, viii. https://psnet.ahrq.gov/issue/multidisciplinary-ap…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867529/psn-pdf
    January 15, 2025 - “I had no idea this happened”: electronic feedback on clinical reasoning for hospitalists. January 15, 2025 Kotwal S, Udayappan KM, Kutheala N, et al. “I had no idea this happened”: electronic feedback on clinical reasoning for hospitalists. J Gen Intern Med. 2024;39(16):3271-3277. doi:10.1007/s11606-024-09058-1. …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47679/psn-pdf
    April 03, 2019 - 'So why didn't you think this baby was ill?' Decision- making in acute paediatrics. April 3, 2019 Roland D, Snelson E. 'So why didn't you think this baby was ill?' Decision-making in acute paediatrics. Arch Dis Child Educ Pract Ed. 2019;104(1):43-48. doi:10.1136/archdischild-2017-313199. https://psnet.ahrq.gov/iss…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847724/psn-pdf
    April 19, 2023 - Defining avoidable healthcare-associated harm in prisons: a mixed-method development study. April 19, 2023 Keers RN, Wainwright V, McFadzean J, et al. Defining avoidable healthcare-associated harm in prisons: a mixed-method development study. PLOS One. 2023;18(3):e0282021. doi:10.1371/journal.pone.0282021. https:/…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43368/psn-pdf
    October 01, 2014 - Improving safety and quality of care with enhanced teamwork through operating room briefings. October 1, 2014 Hicks CW, Rosen MA, Hobson DB, et al. Improving safety and quality of care with enhanced teamwork through operating room briefings. JAMA Surg. 2014;149(8):863-8. doi:10.1001/jamasurg.2014.172. https://psne…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837694/psn-pdf
    July 20, 2022 - Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm. July 20, 2022 Wolf L, Gorman K, Clark J, et al. Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient har…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46872/psn-pdf
    May 09, 2018 - Obstetric Care Consensus No. 5: Severe Maternal Morbidity: Screening and Review. May 9, 2018 Obstetric Care Consensus No. 5: Severe Maternal Morbidity: Screening and Review. Obstet Gynecol. 2016;128(3):e54-60. doi:10.1097/AOG.0000000000001642. https://psnet.ahrq.gov/issue/obstetric-care-consensus-no-5-severe-mater…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46487/psn-pdf
    May 16, 2018 - High Reliability for a Highly Unreliable World: Preparing for Code Blue Through Daily Operations in Healthcare. May 16, 2018 van Stralen D, Byrum SL, Inozu B. North Charleston, SC: CreateSpace Publishing; 2018. ISBN: 1974506371. https://psnet.ahrq.gov/issue/high-reliability-highly-unreliable-world-preparing-code-b…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866732/psn-pdf
    September 18, 2024 - Misuse, abuse and medication errors' adverse events associated with opioids--a systematic review. September 18, 2024 Gustafsson M, Silva V, Valeiro C, et al. Misuse, abuse and medication errors' adverse events associated with opioids--a systematic review. Pharmaceuticals (Basel). 2024;17(8):1009. doi:10.3390/ph1708…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43779/psn-pdf
    May 28, 2015 - Debriefing in the emergency department after clinical events: a practical guide. May 28, 2015 Kessler DO, Cheng A, Mullan PC. Debriefing in the Emergency Department After Clinical Events: A Practical Guide. Ann Emerg Med. 2015;65(6):690-698. doi:10.1016/j.annemergmed.2014.10.019. https://psnet.ahrq.gov/issue/debri…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60196/psn-pdf
    April 01, 2020 - Mask shortage straps pharmacists who need them to keep medicines pure. April 1, 2020 Jewett C, Lupkin S. Health Shots. National Public Radio. March 20, 2020. https://psnet.ahrq.gov/issue/mask-shortage-straps-pharmacists-who-need-them-keep-medicines-pure Disruptions in medication compounding activities can impact s…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60559/psn-pdf
    June 03, 2020 - Omissions of care in nursing home settings: a narrative review. June 3, 2020 Ogletree AM, Mangrum R, Harris Y, et al. Omissions of care in nursing home settings: a narrative review. J Am Med Dir Assoc. 2020;21(5):604-614.e6. doi:10.1016/j.jamda.2020.02.016. https://psnet.ahrq.gov/issue/omissions-care-nursing-home-…
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