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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851457/psn-pdf
    July 19, 2023 - Root causes and preventability of unintentionally retained foreign objects after surgery: a national expert survey from Switzerland. July 19, 2023 Schwappach DLB, Pfeiffer Y. Root causes and preventability of unintentionally retained foreign objects after surgery: a national expert survey from Switzerland. Patient…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837851/psn-pdf
    August 17, 2022 - Medication errors in intensive care units: an umbrella review of control measures. August 17, 2022 Dionisi S, Giannetta N, Liquori G, et al. Medication errors in intensive care units: an umbrella review of control measures. Healthcare (Basel). 2022;10(7):1221. doi:10.3390/healthcare10071221. https://psnet.ahrq.gov…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38014/psn-pdf
    March 02, 2011 - The frequency and significance of discrepancies in the surgical count. March 2, 2011 Greenberg CC, Regenbogen SE, Lipsitz SR, et al. The Frequency and Significance of Discrepancies in the Surgical Count. Ann Surg. 2009;248(2). doi:10.1097/sla.0b013e318181c9a3. https://psnet.ahrq.gov/issue/frequency-and-significanc…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852285/psn-pdf
    August 09, 2023 - Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II. August 9, 2023 ISMP Medication Safety Alert! Acute care edition. July 13, 2023;(4):1-3;July 27, 2023;(5):1-5. https://psnet.ahrq.gov/issue/risk-evaluation-and-mitigation-strategy-rems-programs-and-medication-safety- part…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73114/psn-pdf
    April 07, 2021 - Clinical and financial implications of second-opinion surgical pathology review. April 7, 2021 Johnson SM, Samulski TD, O’Connor SM, et al. Clinical and financial implications of second-opinion surgical pathology review. Am J Clin Pathol. 2021;156(4):559-568. doi:10.1093/ajcp/aqaa263. https://psnet.ahrq.gov/issue/…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73215/psn-pdf
    May 05, 2021 - To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. May 5, 2021 Isherwood P, Waterson P. To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. J Patient Saf Risk Manag. 2021;26(2):64-73. doi:10.1177/2516043521990…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47536/psn-pdf
    March 09, 2019 - Evaluation of wound photography for remote postoperative assessment of surgical site infections. March 9, 2019 Broman KK, Gaskill CE, Faqih A, et al. Evaluation of Wound Photography for Remote Postoperative Assessment of Surgical Site Infections. JAMA Surg. 2019;154(2):117-124. doi:10.1001/jamasurg.2018.3861. htt…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44876/psn-pdf
    February 10, 2016 - The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, System Failures and Lack of Mindfulness. February 10, 2016 Anderson-Fletcher E, Vera D, Abbott J. Houston, TX: Hobbs Center for Public Policy, University of Houston; 2015. https://psnet.ahrq.gov/issue/texas-health-presbyterian-h…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836748/psn-pdf
    March 16, 2022 - Analysis of the interprofessional clinical learning environment for quality improvement and patient safety from perspectives of interprofessional teams. March 16, 2022 Cheng MKW, Collins S, Baron RB, et al. Analysis of the interprofessional clinical learning environment for quality improvement and patient safety f…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47356/psn-pdf
    September 05, 2018 - 'Cyberloafing' in health care: a real risk to patient safety. September 5, 2018 Ross J. 'Cyberloafing' in Health Care: A Real Risk to Patient Safety. J Perianesth Nurs. 2018;33(4):560- 562. doi:10.1016/j.jopan.2018.05.003. https://psnet.ahrq.gov/issue/cyberloafing-health-care-real-risk-patient-safety The health ca…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46867/psn-pdf
    February 20, 2019 - Connecting perspectives on quality and safety: patient- level linkage of incident, adverse event and complaint data. February 20, 2019 de Vos MS, Hamming JF, Chua-Hendriks JJC, et al. Connecting perspectives on quality and safety: patient-level linkage of incident, adverse event and complaint data. BMJ Qual Saf. 2…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73169/psn-pdf
    April 21, 2021 - Application of emergency preparedness principles to a pharmacy department’s approach to a “black swan” event: the COVID-19 pandemic. April 21, 2021 Waldron KM, Schenkat DH, Rao KV, et al. Application of emergency preparedness principles to a pharmacy department’s approach to a “black swan” event: the COVID-19 pand…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40881/psn-pdf
    October 26, 2011 - The effect of two different electronic health record user interfaces on intensive care provider task load, errors of cognition, and performance. October 26, 2011 Ahmed A, Chandra S, Herasevich V, et al. The effect of two different electronic health record user interfaces on intensive care provider task load, error…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47388/psn-pdf
    March 13, 2019 - Artificial intelligence systems for complex decision- making in acute care medicine: a review. March 13, 2019 Lynn LA. Artificial intelligence systems for complex decision-making in acute care medicine: a review. Patient Saf Surg. 2019;13:6. doi:10.1186/s13037-019-0188-2. https://psnet.ahrq.gov/issue/artificial-in…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47896/psn-pdf
    July 10, 2019 - Engaging patients and informal caregivers to improve safety and facilitate person- and family-centered care during transitions from hospital to home: a qualitative descriptive study. July 10, 2019 Backman C, Cho-Young D. Engaging patients and informal caregivers to improve safety and facilitate person- and family…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35404/psn-pdf
    March 11, 2011 - Improving patient safety by identifying side effects from introducing bar coding in medication administration. March 11, 2011 Patterson ES, Cook RI, Render ML. Improving patient safety by identifying side effects from introducing bar coding in medication administration. J Am Med Inform Assoc. 2002;9(5):540-53. htt…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43809/psn-pdf
    February 25, 2015 - Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room. February 25, 2015 Bowermaster R, Miller M, Ashcraft T, et al. Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pedia…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46506/psn-pdf
    October 11, 2017 - Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. October 11, 2017 Wiley K, Davies JM. Edmonton, AB: Canadian Patient Safety Institute; 2017. https://psnet.ahrq.gov/issue/getting-ahead-harm-it-happens-guide-about-proactive-analysis-improving- surgical-car…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60526/psn-pdf
    May 27, 2020 - A qualitative content analysis of retained surgical items: learning from root cause analysis investigations. May 27, 2020 Hibbert PD, Thomas MJW, Deakin A, et al. A qualitative content analysis of retained surgical items: learning from root cause analysis investigations. Int J Qual Health Care. 2020;32(3):184-189. …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46042/psn-pdf
    July 12, 2017 - Implementation science for ambulatory care safety: a novel method to develop context-sensitive interventions to reduce quality gaps in monitoring high-risk patients. July 12, 2017 McDonald KM, Su G, Lisker S, et al. Implementation science for ambulatory care safety: a novel method to develop context-sensitive inte…
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