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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60277/psn-pdf
    January 01, 2021 - Evidence that nurses need to participate in diagnosis: lessons from malpractice claims. April 29, 2020 Gleason KT, Jones RM, Rhodes C, et al. Evidence that nurses need to participate in diagnosis: lessons from malpractice claims. J Patient Saf. 2021;17(8):e959-e963. doi:10.1097/pts.0000000000000621. https://psnet.…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45922/psn-pdf
    April 19, 2017 - Two sides to every story: the Dual Perspectives Method for examining interruptions in healthcare. April 19, 2017 McCurdie T, Sanderson P, Aitken LM, et al. Two sides to every story: The Dual Perspectives Method for examining interruptions in healthcare. Appl Ergon. 2017;58:102-109. doi:10.1016/j.apergo.2016.05.012.…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46124/psn-pdf
    April 17, 2018 - Improving the safety of health information technology requires shared responsibility: it is time we all step up. April 17, 2018 Sittig DF, Belmont E, Singh H. Improving the safety of health information technology requires shared responsibility: It is time we all step up. Healthc (Amst). 2017;6(1):7-12. doi:10.1016/…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41703/psn-pdf
    November 08, 2012 - Anatomy of an incident disclosure: the importance of dialogue. November 8, 2012 Iedema R, Allen S. Anatomy of an incident disclosure: the importance of dialogue. Jt Comm J Qual Patient Saf. 2012;38(10):435-42. https://psnet.ahrq.gov/issue/anatomy-incident-disclosure-importance-dialogue Physician organizations who…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47403/psn-pdf
    November 07, 2018 - Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition. November 7, 2018 Triller D, Myrka A, Gassler J, et al. Defining Minimum Necessary Anticoagulation-Related Communication at Discharge: Consens…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43363/psn-pdf
    September 12, 2016 - Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study. September 12, 2016 Johnston MJ, Arora S, King D, et al. Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study. Surgery. 2014;155(6):989-94. doi:10.1016/j.surg.2014.01.016. https://ps…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46031/psn-pdf
    April 12, 2017 - Chief of Residents for Quality Improvement and Patient Safety: a recipe for a new role in graduate medical education. April 12, 2017 Ferraro K, Zernzach R, Maturo S, et al. Chief of Residents for Quality Improvement and Patient Safety: A Recipe for a New Role in Graduate Medical Education. Mil Med. 2017;182(3):e17…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867229/psn-pdf
    January 01, 2025 - Feasibility of prospective error reporting in home palliative care: a mixed methods study. December 4, 2024 Kurahashi AM, Kim G, Parry N, et al. Feasibility of prospective error reporting in home palliative care: a mixed methods study. Palliat Med. 2025;39(1):22-30. doi:10.1177/02692163241288774. https://psnet.ahr…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60524/psn-pdf
    May 27, 2020 - Varying rates of patient identity verification when using computerized provider order entry. May 27, 2020 Fortman E, Hettinger AZ, Howe JL, et al. Varying rates of patient identity verification when using computerized provider order entry. J Am Med Info Assoc. 2020;27(6):924-928. doi:10.1093/jamia/ocaa047. https:/…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45500/psn-pdf
    September 28, 2016 - PIPc study: development of indicators of potentially inappropriate prescribing in children (PIPc) in primary care using a modified Delphi technique. September 28, 2016 Barry E, O'Brien K, Moriarty F, et al. PIPc study: development of indicators of potentially inappropriate prescribing in children (PIPc) in primary…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44577/psn-pdf
    October 21, 2015 - Improving patient safety in clinical oncology: applying lessons from Normal Accident Theory. October 21, 2015 Chera BS, Mazur L, Buchanan I, et al. Improving Patient Safety in Clinical Oncology: Applying Lessons From Normal Accident Theory. JAMA Oncol. 2015;1(7):958-64. doi:10.1001/jamaoncol.2015.0891. https://psn…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36303/psn-pdf
    October 25, 2010 - Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy. October 25, 2010 Poon EG, Cina J, Churchill WW, et al. Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy. …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36407/psn-pdf
    April 19, 2011 - Adverse events experienced while transferring the critically ill patient from the emergency department to the intensive care unit. April 19, 2011 Gillman L, Leslie G, Williams T, et al. Adverse events experienced while transferring the critically ill patient from the emergency department to the intensive care unit…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843329/psn-pdf
    February 01, 2023 - Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology. February 1, 2023 Chew MM, Rivas S, Chesser M, et al. Improving administration and documentation of enteral nutrition su…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73662/psn-pdf
    September 01, 2021 - Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation using framework analysis and video review. September 1, 2021 Petrosoniak A, Fan M, Hicks CM, et al. Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation u…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60048/psn-pdf
    March 18, 2020 - 'Immunising' physicians against availability bias in diagnostic reasoning: a randomised controlled experiment. March 18, 2020 Mamede S, de Carvalho-Filho MA, de Faria RMD, et al. ‘Immunising’ physicians against availability bias in diagnostic reasoning: a randomised controlled experiment. BMJ Qual Saf. 2020;29(7):…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/862992/psn-pdf
    February 21, 2024 - Evaluating independent double checks in the pediatric intensive care unit: a human factors engineering approach. February 21, 2024 Konwinski L, Steenland C, Miller K, et al. Evaluating independent double checks in the pediatric intensive care unit: a human factors engineering approach. J Patient Saf. 2024;20(3):20…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37891/psn-pdf
    June 09, 2011 - Classifying and predicting errors of inpatient medication reconciliation. June 9, 2011 Pippins JR, Gandhi TK, Hamann C, et al. Classifying and predicting errors of inpatient medication reconciliation. J Gen Intern Med. 2008;23(9):1414-22. doi:10.1007/s11606-008-0687-9. https://psnet.ahrq.gov/issue/classifying-and-…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47069/psn-pdf
    June 18, 2021 - Physical and verbal violence against health care workers. June 18, 2021 Physical and verbal violence against health care workers. Sentinel Event Alert. 2018;59:1-9 (revised June 18, 2021). https://psnet.ahrq.gov/issue/physical-and-verbal-violence-against-health-care-workers The Joint Commission issues sentinel eve…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60361/psn-pdf
    May 20, 2020 - Novel, High-Impact Studies Evaluating Health System and Healthcare Professional Responsiveness to COVID-19 (R01). May 20, 2020 Rockville, MD: Agency for Healthcare Research and Quality; May 14, 2020. https://psnet.ahrq.gov/issue/novel-high-impact-studies-evaluating-health-system-and-healthcare- professional-respo…
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