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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48018/psn-pdf
    July 31, 2019 - PEARLS for systems integration: a modified PEARLS framework for debriefing systems-focused simulations. July 31, 2019 Dubé MM, Reid J, Kaba A, et al. PEARLS for Systems Integration: A Modified PEARLS Framework for Debriefing Systems-Focused Simulations. Simul Healthc. 2019;14(5):333-342. doi:10.1097/SIH.0000000000…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845633/psn-pdf
    March 08, 2023 - Impact of pharmacist interventions provided in the emergency department on quality use of medicines: a systematic review and meta-analysis. March 8, 2023 Atey TM, Peterson GM, Salahudeen MS, et al. Impact of pharmacist interventions provided in the emergency department on quality use of medicines: a systematic rev…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43283/psn-pdf
    June 25, 2014 - Development, implementation, and dissemination of the I- PASS Handoff Curriculum: a multisite educational intervention to improve patient handoffs. June 25, 2014 Starmer AJ, O'Toole JK, Rosenbluth G, et al. Development, implementation, and dissemination of the I- PASS handoff curriculum: A multisite educational in…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45878/psn-pdf
    September 20, 2017 - Development of a trigger tool to identify adverse events and harm in emergency medical services. September 20, 2017 Howard IL, Bowen JM, Shaikh LAHA, et al. Development of a trigger tool to identify adverse events and harm in Emergency Medical Services. Emerg Med J. 2017;34(6):391-397. doi:10.1136/emermed-2016- 20…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50424/psn-pdf
    September 04, 2019 - From box ticking to the black box: the evolution of operating room safety. September 4, 2019 Goldenberg MG, Elterman D. From box ticking to the black box: the evolution of operating room safety. World J Urol. 2019;38(6):1369-1372. doi:10.1007/s00345-019-02886-5. https://psnet.ahrq.gov/issue/box-ticking-black-box-e…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50700/psn-pdf
    January 01, 2020 - Developing health care organizations that pursue learning and exploration of diagnostic excellence: an action plan. December 4, 2019 Singh H, Upadhyay DK, Torretti D. Developing Health Care Organizations That Pursue Learning and Exploration of Diagnostic Excellence: An Action Plan. Acad Med. 2020;95(8):1172-1178. …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37610/psn-pdf
    June 16, 2011 - Is yours a learning organization? June 16, 2011 Garvin DA, Edmondson A, Gino F. Is yours a learning organization? Harv Bus Rev. 2008;86(3):109-16, 134. https://psnet.ahrq.gov/issue/yours-learning-organization Key tenets of improving patient safety at the organizational level include taking a systems approach to s…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837772/psn-pdf
    August 03, 2022 - Translating electronic health record-based patient safety algorithms from research to clinical practice at multiple sites. August 3, 2022 Zimolzak AJ, Singh H, Murphy DR, et al. BMJ Health Care Inform. 2022;29(1):e100565. https://psnet.ahrq.gov/issue/translating-electronic-health-record-based-patient-safety-algori…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42859/psn-pdf
    March 20, 2014 - Sustainable, effective implementation of a surgical preprocedural checklist: an "attestation" format for all operating team members. March 20, 2014 Porter AJ, Narimasu JY, Mulroy MF, et al. Sustainable, effective implementation of a surgical preprocedural checklist: an "attestation" format for all operating team m…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35159/psn-pdf
    January 02, 2017 - Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge. January 2, 2017 Rodehaver C, Fearing D. Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge. Jt Comm J Qual Patient Saf. 2005;31(7):406-13. https://psnet.ahrq.gov…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47068/psn-pdf
    June 25, 2018 - The need for closed-loop systems for management of abnormal test results. June 25, 2018 Zuccotti G, Samal L, Maloney FL, et al. The Need for Closed-Loop Systems for Management of Abnormal Test Results. Ann Intern Med. 2018;168(11):820-821. doi:10.7326/M17-2425. https://psnet.ahrq.gov/issue/need-closed-loop-systems…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46176/psn-pdf
    October 04, 2017 - Incidence and severity of prescribing errors in parenteral nutrition for pediatric inpatients at a neonatal and pediatric intensive care unit. October 4, 2017 Hermanspann T, Schoberer M, Robel-Tillig E, et al. Incidence and Severity of Prescribing Errors in Parenteral Nutrition for Pediatric Inpatients at a Neonat…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838315/psn-pdf
    October 12, 2022 - Contributors to diagnostic error or delay in the acute care setting: a survey of clinical stakeholders. October 12, 2022 Redmond S, Barwise A, Zornes S, et al. Contributors to diagnostic error or delay in the acute care setting: a survey of clinical stakeholders. Health Serv Insights. 2022;15:117863292211235. doi:…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45341/psn-pdf
    July 27, 2016 - How to avoid catastrophic events on the ward. July 27, 2016 Bein B, Seewald S, Gräsner J-T. How to avoid catastrophic events on the ward. Best Pract Res Clin Anaesthesiol. 2016;30(2):237-45. doi:10.1016/j.bpa.2016.04.003. https://psnet.ahrq.gov/issue/how-avoid-catastrophic-events-ward Hospitals require robust esca…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46175/psn-pdf
    September 24, 2017 - Applying lessons from social psychology to transform the culture of error disclosure. September 24, 2017 Han J, LaMarra D, Vapiwala N. Applying lessons from social psychology to transform the culture of error disclosure. Med Educ. 2017;51(10):996-1001. doi:10.1111/medu.13345. https://psnet.ahrq.gov/issue/applying-…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74271/psn-pdf
    January 19, 2022 - Improving shared situation awareness for high-risk therapies in hospitalized children. January 19, 2022 Sosa T, Mayer B, Chakkalakkal B, et al. Improving shared situation awareness for high-risk therapies in hospitalized children. Hosp Pediatr. 2022;12(1):37-46. doi:10.1542/hpeds.2021-006193. https://psnet.ahrq.go…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849123/psn-pdf
    May 17, 2023 - Maximizing student potential: lessons for pharmacy programs from the patient safety movement. May 17, 2023 Abebe E, Bao A, Kokkinias P, et al. Maximizing student potential: lessons for pharmacy programs from the patient safety movement. Explor Res Clin Soc Pharm. 2023;9:100216. doi:10.1016/j.rcsop.2022.100216. htt…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46011/psn-pdf
    January 17, 2018 - Health and Social Care Ergonomics: Patient Safety in Practice. January 17, 2018 Hignett S, Albolino S, Catchpole K, eds. Ergonomics. 2018;61:1-161. https://psnet.ahrq.gov/issue/health-and-social-care-ergonomics-patient-safety-practice Human factors engineering strategies offer a range of solutions to improve proce…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50922/psn-pdf
    February 19, 2020 - An Organisation Losing its Memory? Patient Safety Alerts: Implementation, Monitoring and Regulation in England February 19, 2020 Cousins D. Croydon, UK: Accidents against Medical Accidents; 2020. https://psnet.ahrq.gov/issue/organisation-losing-its-memory-patient-safety-alerts-implementation- monitoring-and-regul…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73524/psn-pdf
    July 21, 2021 - Intravenous admixture preparation considerations, Parts 9-A and 9-B: error prevention in intravenous admixture preparation. July 21, 2021 Allen LV, Jr. Int J Pharm Compd. 2021;25:131-139; 222-229. https://psnet.ahrq.gov/issue/intravenous-admixture-preparation-considerations-parts-9-and-9-b-error- prevention-…
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