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  1. 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…
  2. 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…
  3. 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…
  4. psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
    February 23, 2011 - Patient Identification Errors: A Systems Challenge Citation Text: Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Googl…
  5. psnet.ahrq.gov/web-mm/hard-swallow
    April 26, 2023 - Hard to Swallow Citation Text: Driver J. Hard to Swallow. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  6. psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
    October 01, 2018 - CVC Removal: A Procedure Like Any Other Citation Text: Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33743/psn-pdf
    December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit December 1, 2012 Vasilevskis EE, Ely WE, Dittus RS. Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit. PSNet [internet]. 2012. https://psnet.ahrq.gov…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49609/psn-pdf
    October 01, 2010 - Dangerous Dialysis October 1, 2010 Holley JL. Dangerous Dialysis . PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/dangerous-dialysis Case Objectives List common errors that occur in dialysis units. Describe steps that can be taken by dialysis units to prevent these common errors. Describe the role of the …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867698/psn-pdf
    October 01, 2024 - Toolkit for MRSA Prevention in ICU & Non-ICU Settings. October 1, 2024 Agency for Healthcare Research and Quality. Toolkit for MRSA Prevention in ICU & Non-ICU Settings. October 2024. https://psnet.ahrq.gov/issue/toolkit-mrsa-prevention-icu-non-icu-settings Methicillin-resistant Staphylococcus aureus (MRSA) infect…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36110/psn-pdf
    April 04, 2024 - Sentinel Event Data Summary. April 4, 2024 Joint Commission. https://psnet.ahrq.gov/issue/sentinel-event-statistics-1995-2019 This website provides sentinel event data reported to The Joint Commission, which includes information on sentinel events reported from January through December 2023. Falls, wrong surgery a…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50595/psn-pdf
    January 01, 2020 - Clinical reasoning as a core competency. October 30, 2019 Connor DM, Durning SJ, Rencic J. Clinical Reasoning as a Core Competency. Acad Med. 2020;95(8):1166-1171. doi:10.1097/acm.0000000000003027. https://psnet.ahrq.gov/issue/clinical-reasoning-core-competency Enhancing clinical reasoning skill, particularly amon…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33922/psn-pdf
    August 05, 2009 - The importance of cognitive errors in diagnosis and strategies to minimize them. August 5, 2009 Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780. https://psnet.ahrq.gov/issue/importance-cognitive-errors-diagnosis-and-strategies-minimize-them…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836868/psn-pdf
    April 06, 2022 - HEAR Her Concerns. April 6, 2022 National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health; Centers for Disease Control and Prevention.  https://psnet.ahrq.gov/issue/hear-her-concerns Maternal harm during and after pregnancy is a sentinel event. This campaign encoura…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35015/psn-pdf
    June 16, 2011 - Keeping Patients Safe: Transforming the Work Environment of Nurses. June 16, 2011 Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services. Washington, DC: The National Academies Press; 2004. ISBN: 9780309090674. https://psnet.ahrq.gov/issue/keeping-patients-safe-trans…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852458/psn-pdf
    June 01, 2019 - The patient's role in patient safety. June 1, 2019 Corina I, Abram M, Halperin D. The patient's role in patient safety. Obstet Gynecol Clin North Am. 2019;46(2):215-225. doi:10.1016/j.ogc.2019.01.004. https://psnet.ahrq.gov/issue/patients-role-patient-safety Patients and their families can play an important role i…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35523/psn-pdf
    December 14, 2010 - ISMP Medication Errors Reporting Program. December 14, 2010 Institute for Safe Medication Practices https://psnet.ahrq.gov/issue/ismp-medication-errors-reporting-program The Institute for Safe Medication Practices (ISMP) administers this national reporting program, which collects confidential reports of medication…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35327/psn-pdf
    March 15, 2017 - Common Program Requirements. The Learning and Working Environment (Duty Hours). March 15, 2017 Accreditation Council for Graduate Medical Education. https://psnet.ahrq.gov/issue/common-program-requirements-learning-and-working-environment-duty-hours This website provides information about efforts to study and set …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44873/psn-pdf
    March 21, 2016 - Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. March 21, 2016 Cambridge, MA: CRICO Strategies; 2016. https://psnet.ahrq.gov/issue/malpractice-risks-communication-failures-2015-annual-benchmarking-report Communication failures are known to contribute to medical errors. Analyzing more …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47999/psn-pdf
    May 15, 2019 - Pregnancy-related deaths: saving women’s lives before, during and after delivery. May 15, 2019 CDC Vital Signs. May 7, 2019. https://psnet.ahrq.gov/issue/pregnancy-related-deaths-saving-womens-lives-during-and-after-delivery Maternal morbidity and mortality is a worldwide patient safety problem. This analysis desc…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38022/psn-pdf
    August 27, 2008 - Hospitals try to calm doctors' outbursts: medical road rage affecting patient safety, group says. August 27, 2008 Kowalczyk L. https://psnet.ahrq.gov/issue/hospitals-try-calm-doctors-outbursts-medical-road-rage-affecting-patient- safety-group-says This article describes how physician outbursts can affect patient …

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