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9921. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72855/psn-pdf
      March 17, 2021 - We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptations. March 17, 2021 Panda N, Etheridge JC, Singh T, et al. The WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptation…

9922. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50447/psn-pdf
      October 09, 2019 - Patient safety incidents in advance care planning for serious illness: a mixed-methods analysis October 9, 2019 Dinnen T, Williams H, Yardley S, et al. Patient safety incidents in advance care planning for serious illness: a mixed-methods analysis. BMJ Support Palliat Care. 2019. doi:10.1136/bmjspcare-2019-001824. …

9923. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/849340/psn-pdf
      May 24, 2023 - Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment for Persons with Mental Health Disabilities. May 24, 2023 Massachusetts Protection and Advocacy. Boston, MA:  Disability Law Center; May 8, 2023. https://psnet.ahrq.gov/issue/death-inside-lemuel-shattuck-hospital-case-study-medical-treat…

9924. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46285/psn-pdf
      August 02, 2017 - A hospital is not just a factory, but a complex adaptive system—implications for perioperative care. August 2, 2017 Mahajan A, Islam SD, Schwartz MJ, et al. A Hospital Is Not Just a Factory, but a Complex Adaptive System-Implications for Perioperative Care. Anesth Analg. 2017;125(1):333-341. doi:10.1213/ANE.000000…

9925. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34732/psn-pdf
      May 09, 2015 - A Tale of Two Stories: Contrasting Views of Patient Safety. May 9, 2015 Cook RI, Woods DD, Miller C. Chicago, IL: National Patient Safety Foundation; 1997. https://psnet.ahrq.gov/issue/tale-two-stories-contrasting-views-patient-safety A report from a workshop, this document is a well-written look at the difference…

9926. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35467/psn-pdf
      March 11, 2011 - The impact of electronic health records on time efficiency of physicians and nurses: a systematic review. March 11, 2011 Poissant L, Pereira J, Tamblyn R, et al. The impact of electronic health records on time efficiency of physicians and nurses: a systematic review. J Am Med Inform Assoc. 2005;12(5):505-16. https…

9927. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73603/psn-pdf
      August 18, 2021 - The patients' perspective: hematological cancer patients' experiences of adverse events as part of care. August 18, 2021 Bryant J, Carey M, Sanson-Fisher R, et al. The patients' perspective: hematological cancer patients' experiences of adverse events as part of care. J Patient Saf. 2021;17(5):e387-e392. doi:10.10…

9928. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866556/psn-pdf
      August 21, 2024 - Digital maturity as a predictor of quality and safety outcomes in US hospitals: cross-sectional observational study. August 21, 2024 Snowdon A, Hussein A, Danforth M, et al. Digital maturity as a predictor of quality and safety outcomes in US hospitals: cross-sectional observational study. J Med Internet Res. 2024…

9929. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866636/psn-pdf
      January 01, 2025 - Hospital commitments to address diagnostic errors: an assessment of 95 US hospitals. September 4, 2024 Campione Russo A, Tilly J?L, Kaufman L, et al. Hospital commitments to address diagnostic errors: an assessment of 95 US hospitals. J Hosp Med. 2025;20(2):120-134. doi:10.1002/jhm.13485. https://psnet.ahrq.gov/is…

9930. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50573/psn-pdf
      October 23, 2019 - Preventing patient harm via adverse event review: An APSA survey regarding the role of morbidity and mortality (M&M) conference. October 23, 2019 Berman L, Ottosen M, Renaud E, et al. Preventing patient harm via adverse event review: An APSA survey regarding the role of morbidity and mortality (M&M) conference. J …

9931. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44515/psn-pdf
      February 23, 2018 - The Expert Panel Report to Texas Health Resources Leadership on the 2014 Ebola Events. February 23, 2018 Cortese D, Abbott P, Chassin M, Lyon GM III, Riley WJ. Dallas, TX: Texas Health Resources Leadership; 2015. https://psnet.ahrq.gov/issue/expert-panel-report-texas-health-resources-leadership-2014-ebola-events …

9932. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44580/psn-pdf
      January 13, 2016 - Computerized Prescriber Order Entry Medication Safety (CPOEMS): Uncovering and Learning From Issues and Errors. January 13, 2016 Brigham and Women's Hospital, Harvard Medical School, Partners HealthCare. Silver Spring, MD: US Food and Drug Administration; December 15, 2015. https://psnet.ahrq.gov/issue/computeriz…

9933. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73435/psn-pdf
      June 30, 2021 - Incidence, origins and avoidable harm of missed opportunities in diagnosis: longitudinal patient record review in 21 English general practices. June 30, 2021 Cheraghi-Sohi S, Holland F, Singh H, et al. Incidence, origins and avoidable harm of missed opportunities in diagnosis: longitudinal patient record review in…

9934. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838910/psn-pdf
      October 26, 2022 - Rates of surgical consultations after emergency department admission in Black and White Medicare patients. October 26, 2022 Roberts SE, Rosen CB, Keele LJ, et al. Rates of surgical consultations after emergency department admission in Black and White Medicare patients. JAMA Surg. 2022;157(12):1097-1104. doi:10.10…

9935. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60316/psn-pdf
      January 01, 2021 - Hospital-acquired Conditions Reduction Program, patient safety, and Magnet designation in the United States. May 13, 2020 Hamadi H, Borkar SR, DHA LRM, et al. Hospital-acquired Conditions Reduction Program, patient safety, and Magnet designation in the United States. J Patient Saf. 2021;17(8):e1814-e1820. doi:10.1…

9936. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72730/psn-pdf
      February 10, 2021 - From fable to reality at Parkland Hospital: the impact of evidence-based design strategies on patient safety, healing, and satisfaction in an adult inpatient environment. February 10, 2021 Rich RK, Jimenez FE, Puumala SE, et al. From Fable to Reality at Parkland Hospital: The Impact of Evidence-Based Design Strat…

9937. Operation Sequence Diagram | Digital Healthcare Research
      digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/operation-sequence-diagram
      January 01, 2023 - Operation Sequence Diagram Acronym OSD Description Operation sequence diagrams (OSD) are graphical representations of team interaction in a network. They portray how tasks are performed and how individuals interact over time. Uses To portray graphically how teams interact in a networ…

9938. Using the AHRQ Pharmacy Survey on Patient Safety Culture (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/pharmacy/pharmwebinar/amermanslides.pdf
      June 02, 2025 - Using the AHRQ Pharmacy Survey on Patient Safety Culture Safety Survey Dawn Amerman Manager Dexter Pharmacy and Village Pharmacy II Reasons for Taking the Survey • Provided staff with an opportunity to give uncensored feedback • Offered staff a sense of being part of the solutions • Let staff know t…

9939. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867340/psn-pdf
      December 11, 2024 - Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative care: a mixed methods analysis. December 11, 2024 Brown AJ, Yardley S, Bowers B, et al. Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative care: a mixed…

9940. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39862/psn-pdf
      September 24, 2016 - Errors and electronic prescribing: a controlled laboratory study to examine task complexity and interruption effects. September 24, 2016 Magrabi F, Li SYW, Day R, et al. Errors and electronic prescribing: a controlled laboratory study to examine task complexity and interruption effects. J Am Med Inform Assoc. 2010;…