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8601. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38750/psn-pdf
      July 01, 2009 - Probability error in diagnosis: the conjunction fallacy among beginning medical students. July 1, 2009 Rao G. Probability error in diagnosis: the conjunction fallacy among beginning medical students. Fam Med. 2009;41(4):262-5. https://psnet.ahrq.gov/issue/probability-error-diagnosis-conjunction-fallacy-among-begin…

8602. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43748/psn-pdf
      December 03, 2014 - New enteral connectors: raising awareness. December 3, 2014 Guenter P. New Enteral Connectors. Nutrition in Clinical Practice. 2014;29(5). doi:10.1177/0884533614543330. https://psnet.ahrq.gov/issue/new-enteral-connectors-raising-awareness Redesigning tubing connectors according to new ISO standards has the potenti…

8603. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37086/psn-pdf
      October 03, 2011 - Failure mode and effects analysis: a useful tool for risk identification and injury prevention. October 3, 2011 Paparella S. Failure mode and effects analysis: a useful tool for risk identification and injury prevention. Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Ass…

8604. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35413/psn-pdf
      September 11, 2009 - Lessons learned: basic evidence-based advice for preventing medication errors in children. September 11, 2009 Thomas DO. Lessons learned: basic evidence-based advice for preventing medication errors in children. Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Association.…

8605. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46596/psn-pdf
      November 01, 2017 - Infection prevention and control in pediatric ambulatory settings. November 1, 2017 Rathore MH, Jackson MA, AAP Committee on Infections Diseases. Pediatrics. 2017;140(5):e20172857. https://psnet.ahrq.gov/issue/infection-prevention-and-control-pediatric-ambulatory-settings Patient safety in the ambulatory environme…

8606. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46293/psn-pdf
      January 01, 2021 - Development of the barriers to error disclosure assessment tool. September 27, 2017 Welsh D, Zephyr D, Pfeifle AL, et al. Development of the Barriers to Error Disclosure Assessment Tool. J Patient Saf. 2021;17(5):363-374. doi:10.1097/PTS.0000000000000331. https://psnet.ahrq.gov/issue/development-barriers-error-dis…

8607. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42978/psn-pdf
      February 26, 2014 - The Francis Report: One Year On. February 26, 2014 Thorlby R, Smith J, Williams S, Dayan M. London, UK: Nuffield Trust; February 2014.  https://psnet.ahrq.gov/issue/francis-report-one-year This publication offers insights from acute care hospital staff in England regarding recommendations from the Francis rep…

8608. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38649/psn-pdf
      May 20, 2009 - Managing the adverse event occurring during elective, ambulatory pediatric surgery. May 20, 2009 Skarsgard ED. Managing the adverse event occurring during elective, ambulatory pediatric surgery. Semin Pediatr Surg. 2009;18(2):122-4. doi:10.1053/j.sempedsurg.2009.02.013. https://psnet.ahrq.gov/issue/managing-advers…

8609. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35083/psn-pdf
      March 29, 2007 - Patient Safety: Achieving a New Standard for Care. March 29, 2007 Aspden P ed, Committee for Data Standards for Patient Safety, Institute of Medicine. Washington DC: National Academies Press; 2004. ISBN 0309090776. https://psnet.ahrq.gov/issue/patient-safety-achieving-new-standard-care This report details findings…

8610. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73860/psn-pdf
      September 22, 2021 - A system safety approach to assessing risks in the sepsis treatment process. September 22, 2021 Kaya GK. A system safety approach to assessing risks in the sepsis treatment process. Appl Ergon. 2021;94:103408. doi:10.1016/j.apergo.2021.103408. https://psnet.ahrq.gov/issue/system-safety-approach-assessing-risks-sep…

8611. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44978/psn-pdf
      June 01, 2016 - Josie's Story: A Patient Safety Curriculum. June 1, 2016 Kaprielian VS, Sullivan DT, eds. Chapel Hill, NC: Josie King Foundation; Duke University School of Medicine; 2013. https://psnet.ahrq.gov/issue/josies-story-patient-safety-curriculum The experience of Sorrel King and the death of her daughter has motivated h…

8612. Building Safety Culture and Strengthening Hospital Safety Systems | PSNet
      psnet.ahrq.gov/training-catalog/building-safety-culture-and-strengthening-hospital-safety-systems
      July 07, 2025 - Building Safety Culture and Strengthening Hospital Safety Systems Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Organization: Organization Hospital Quality Institute E…

8613. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867772/psn-pdf
      September 01, 2013 - Universal ICU Decolonization: An Enhanced Protocl. September 1, 2013 Agency for Healthcare Research and Quality. Universal ICU Decolonization: An Enhanced Protocol. https://psnet.ahrq.gov/issue/universal-icu-decolonization-enhanced-protocl Methicillin-resistant?Staphylococcus aureus (MRSA) is a known threat to pati…

8614. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35349/psn-pdf
      November 18, 2011 - Leadership Guide to Patient Safety: Resources and Tools for Establishing and Maintaining Patient Safety. November 18, 2011 Botwinick L, Bisognano M, Haraden C. Cambridge, MA: Institute for Healthcare Improvement; 2006. https://psnet.ahrq.gov/issue/leadership-guide-patient-safety-resources-and-tools-establishin…

8615. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43371/psn-pdf
      June 19, 2019 - Medication Safety Officer's Handbook. June 19, 2019 Larson CM, Saine D, eds. Bethesda, MD: American Society of Health-System Pharmacists; 2013. ISBN: 9781585282104. https://psnet.ahrq.gov/issue/medication-safety-officers-handbook This book provides information about medication errors and quality improvement to gui…

8616. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38297/psn-pdf
      May 21, 2014 - Assessment of the AHRQ Patient Safety Initiative: Focus on Implementation and Dissemination Evaluation Report III. May 21, 2014 Farley DO, Damberg CL, Ridgely MS, et al. Santa Monica, CA: RAND Corporation; 2007. ISBN: 9780833042170 https://psnet.ahrq.gov/issue/assessment-ahrq-patient-safety-initiative-focus-imple…

8617. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853976/psn-pdf
      September 27, 2023 - Disclosure of Medical Errors. September 27, 2023 Irving, TX: American College of Emergency Physicians; 2023. https://psnet.ahrq.gov/issue/disclosure-medical-errors Error disclosure is difficult yet important for patient and clinician psychological healing. This statement provides guidance to address barriers to em…

8618. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38007/psn-pdf
      September 05, 2008 - Building a Culture of Patient Safety: Report of the Commission on Patient Safety and Quality Assurance. September 5, 2008 Dublin, Ireland: Department of Health & Children, Commission on Patient Safety and Quality Assurance; 2008. ISBN: 9781406421835. https://psnet.ahrq.gov/issue/building-culture-patient-safety-rep…

8619. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40728/psn-pdf
      October 21, 2011 - What prevents incident disclosure, and what can be done to promote it? October 21, 2011 Iedema R, Allen S, Sorensen R, et al. What prevents incident disclosure, and what can be done to promote it? Jt Comm J Qual Patient Saf. 2011;37(9):409-417. https://psnet.ahrq.gov/issue/what-prevents-incident-disclosure-and-wha…

8620. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46617/psn-pdf
      February 21, 2018 - Supporting second victims. February 21, 2018 Quick Safety. January 22, 2018;(39):1-3. https://psnet.ahrq.gov/issue/supporting-second-victims Involvement in patient harm can result in serious psychological consequences for health care workers. This newsletter article describes problems second victims may experience…