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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72654/psn-pdf
    January 20, 2020 - What is an ethically informed approach to managing patient safety risk during discharge planning? January 20, 2020 West JC. What Is an Ethically Informed Approach to Managing Patient Safety Risk During Discharge Planning? AMA J Ethics. 2020;22(!1):e919-e923. doi:10.1001/amajethics.2020.919. https://psnet.ahrq.gov/…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45859/psn-pdf
    August 03, 2017 - Root cause analysis and actions for the prevention of medical errors: quality improvement and resident education. August 3, 2017 Charles R, Hood B, DeRosier JM, et al. Root Cause Analysis and Actions for the Prevention of Medical Errors: Quality Improvement and Resident Education. Orthopedics. 2017;40(4):e628-e635…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836962/psn-pdf
    April 20, 2022 - Using human factors and ergonomics principles to prevent inpatient falls. April 20, 2022 Kwok Y-ting, Lam M-sang. Using human factors and ergonomics principles to prevent inpatient falls. BMJ Open Qual. 2022;11(1):e001696. doi:10.1136/bmjoq-2021-001696. https://psnet.ahrq.gov/issue/using-human-factors-and-ergonomi…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45098/psn-pdf
    May 04, 2016 - Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical Research—Final Report. May 4, 2016 The Clinical Center Working Group Report to the Advisory Committee to the Director, National Institutes of Health. Bethesda, MD; National Institutes of Health; April 2016. https://psnet.ahrq.gov/issue/reducing…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/860718/psn-pdf
    January 17, 2024 - Impact of hospital accreditation on quality improvement in healthcare: a systematic review. January 17, 2024 Alhawajreh MJ, Paterson AS, Jackson WJ. Impact of hospital accreditation on quality improvement in healthcare: a systematic review. PLoS ONE. 2023;18(12):e0294180. doi:10.1371/journal.pone.0294180. https://…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43909/psn-pdf
    March 11, 2015 - Summary and frequency of barriers to adoption of CPOE in the US. March 11, 2015 Kruse CS, Goetz K. Summary and frequency of barriers to adoption of CPOE in the U.S. J Med Syst. 2015;39(2):15. doi:10.1007/s10916-015-0198-2. https://psnet.ahrq.gov/issue/summary-and-frequency-barriers-adoption-cpoe-us Although compu…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849601/psn-pdf
    May 31, 2023 - VHA's movement for change: implementing high- reliability principles and practices. May 31, 2023 Cox GR, Starr LM. VHA's movement for change: implementing high-reliability principles and practices. J Healthc Manag. 2023;68(3):151-157. doi:10.1097/jhm-d-23-00056. https://psnet.ahrq.gov/issue/vhas-movement-change-im…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44534/psn-pdf
    April 25, 2016 - Addressing disease-related malnutrition in hospitalized patients: a call for a national goal. April 25, 2016 Guenter P, Jensen G, Patel V, et al. Addressing Disease-Related Malnutrition in Hospitalized Patients: A Call for a National Goal. Jt Comm J Qual Patient Saf. 2015;41(10):469-473. https://psnet.ahrq.gov/iss…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837432/psn-pdf
    June 15, 2022 - Adopt strategies to manage look-alike and/or sound-alike medication name mix-ups. June 15, 2022 ISMP Medication Safety Alert! Acute care edition. June 2, 2022;27(11):1-4. https://psnet.ahrq.gov/issue/adopt-strategies-manage-look-alike-andor-sound-alike-medication-name-mix- ups Minimizing look-alike/sound-alike me…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50451/psn-pdf
    October 09, 2019 - Pharmacist-led, video-stimulated feedback to reduce prescribing errors in doctors-in-training: A mixed methods evaluation October 9, 2019 Parker H, Farrell O, Bethune R, et al. Pharmacist-led, video-stimulated feedback to reduce prescribing errors in doctors-in-training: A mixed methods evaluation. Br J Clin Pharm…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838325/psn-pdf
    October 12, 2022 - Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021. October 12, 2022 Washington, DC: VA Office of the Inspector General; September 15, 2022. Report no. 22-00815-232. https://psnet.ahrq.gov/issue/comprehensive-healthcare…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861778/psn-pdf
    January 31, 2024 - Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee. January 31, 2024 Washington, DC: The Veterans Affairs Inspector General; January 10, 2024. Report No. 23-00777-52. https://psnet.ahrq.gov/issue/care-deficiencies-and-l…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46722/psn-pdf
    March 20, 2018 - Nurses' clinical reasoning practices that support safe medication administration: an integrative review of the literature. March 20, 2018 Rohde E, Domm E. Nurses' clinical reasoning practices that support safe medication administration: An integrative review of the literature. J Clin Nurs. 2018;27(3-4):e402-e411. …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42567/psn-pdf
    September 11, 2013 - What happens to the medication regimens of older adults during and after an acute hospitalization? September 11, 2013 Harris CM, Sridharan A, Landis R, et al. What happens to the medication regimens of older adults during and after an acute hospitalization? J Patient Saf. 2013;9(3):150-3. doi:10.1097/PTS.0b013e3182…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73505/psn-pdf
    July 21, 2021 - Improving medication reconciliation with comprehensive evaluation at a Veterans Affairs skilled-nursing facility. July 21, 2021 Baughman AW, Triantafylidis LK, O'Neil N, et al. Improving medication reconciliation with comprehensive evaluation at a Veterans Affairs skilled-nursing facility. Jt Comm J Qual Patient Sa…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866447/psn-pdf
    August 07, 2024 - Older adults are often misdiagnosed. Specialized ERs and trained clinicians can help. August 7, 2024 Milne-Tyte A. Older adults are often misdiagnosed. Specialized ERs and trained clinicians can help. Health Shots. National Public Radio. July 30, 2024; https://psnet.ahrq.gov/issue/older-adults-are-often-misdiagnos…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45698/psn-pdf
    January 11, 2017 - Design and testing of the safety agenda mobile app for managing health care managers' patient safety responsibilities. January 11, 2017 Mira JJ, Carrillo I, Fernandez C, et al. Design and Testing of the Safety Agenda Mobile App for Managing Health Care Managers' Patient Safety Responsibilities. JMIR MHealth UHealt…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45768/psn-pdf
    July 02, 2017 - What patients' complaints and praise tell the health practitioner: implications for health care quality. A qualitative research study. July 2, 2017 Mattarozzi K, Sfrisi F, Caniglia F, et al. What patients' complaints and praise tell the health practitioner: implications for health care quality. A qualitative resea…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45563/psn-pdf
    October 19, 2016 - Using a change model to reduce the risk of surgical site infection. October 19, 2016 Burden M. Using a change model to reduce the risk of surgical site infection. Br J Nurs. 2016;25(17):949- 955. https://psnet.ahrq.gov/issue/using-change-model-reduce-risk-surgical-site-infection Surgical site infections can resul…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39638/psn-pdf
    July 02, 2014 - Teaching quality improvement and patient safety to trainees: a systematic review. July 2, 2014 Wong BM, Etchells E, Kuper A, et al. Teaching quality improvement and patient safety to trainees: a systematic review. Acad Med. 2010;85(9):1425-39. doi:10.1097/ACM.0b013e3181e2d0c6. https://psnet.ahrq.gov/issue/teaching…
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