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8721. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49422/psn-pdf
      November 01, 2003 - 40 of K November 1, 2003 Lesar TS. 40 of K. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/40-k The Case An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…

8722. 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 …

8723. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37835/psn-pdf
      July 31, 2008 - Medical students' experiences with medical errors: an analysis of medical student essays. July 31, 2008 Martinez W, Lo B. Medical students' experiences with medical errors: an analysis of medical student essays. Med Educ. 2008;42(7):733-41. doi:10.1111/j.1365-2923.2008.03109.x. https://psnet.ahrq.gov/issue/medical…

8724. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43684/psn-pdf
      November 26, 2014 - Rapid response systems. November 26, 2014 Hillman KM, Chen J, Jones D. Rapid response systems. Med J Aust. 2014;201(9):519-21. https://psnet.ahrq.gov/issue/rapid-response-systems Rapid response systems have been widely accepted as a method to improve outcomes of hospitalized patients demonstrating signs of rapid d…

8725. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44623/psn-pdf
      November 11, 2015 - Quality, Safety, and Noninterpretive Skills. November 11, 2015 Kruskal JB, Kung JW, eds. Radiographics. 2015;35(6):1627-1848. https://psnet.ahrq.gov/issue/quality-safety-and-noninterpretive-skills Increased radiation exposure has emerged as a patient safety problem, with the potential to result in harm for provide…

8726. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39865/psn-pdf
      May 28, 2014 - Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction, Third Edition. May 28, 2014 Oakbrook Terrace, IL: Joint Commission Resources; 2010. ISBN: 9781599404066. https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-health-care-proactive-risk-reduction-third- edition This publication p…

8727. 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…

8728. 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…

8729. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44068/psn-pdf
      April 15, 2015 - Contemporary View of Medication-Related Harm. A New Paradigm. April 15, 2015 National Coordinating Council for Medication Error Reporting and Prevention; NCCMERP. https://psnet.ahrq.gov/issue/contemporary-view-medication-related-harm-new-paradigm Medication errors are a common factor in health care–associated harm…

8730. 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…

8731. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45155/psn-pdf
      May 25, 2016 - Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes. May 25, 2016 Wolfe H, Zebuhr C, Topjian AA, et al. Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes*. Crit Care Med. 2014;42(7):1688-95. doi:10.1097/CCM.0000000000000327. https://psnet.ahrq.gov/issue/interdiscipli…

8732. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45747/psn-pdf
      December 21, 2016 - Implementing No Interruption Zones in the perioperative environment. December 21, 2016 Wright I. Implementing No Interruption Zones in the Perioperative Environment. AORN J. 2016;104(6):536- 540. doi:10.1016/j.aorn.2016.09.018. https://psnet.ahrq.gov/issue/implementing-no-interruption-zones-perioperative-environme…

8733. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35397/psn-pdf
      September 10, 2009 - The National Medical Error Disclosure and Compensation (MEDiC) Act. September 10, 2009 Rodham-Clinton H; Obama B. 109th Congress. 1st Session. S. 1784. September 28, 2005. https://psnet.ahrq.gov/issue/national-medical-error-disclosure-and-compensation-medic-act This bill, introduced to the Senate by Senators Clint…

8734. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41470/psn-pdf
      November 15, 2024 - Hospital Safety Grade. November 15, 2024 Leapfrog Group https://psnet.ahrq.gov/issue/hospital-safety-grade Drawing from data reported by the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medic…

8735. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836754/psn-pdf
      March 16, 2022 - State of science: evolving perspectives on ‘human error’. March 16, 2022 Read GJM, Shorrock S, Walker GH, et al. State of science: evolving perspectives on ‘human error’. Ergonomics. 2021;64(9):1091-1114. doi:10.1080/00140139.2021.1953615. https://psnet.ahrq.gov/issue/state-science-evolving-perspectives-human-error…

8736. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45968/psn-pdf
      October 24, 2024 - State of Care. October 24, 2024 Newcastle Upon Tyne, UK: Care Quality Commission; October 2024. https://psnet.ahrq.gov/issue/state-care This website provides access to an annual report that summarizes National Health Service hospital and social care performance across a range of care quality metrics at both the tr…

8737. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47050/psn-pdf
      April 18, 2018 - Improving Physician Well-Being, Restoring Meaning in Medicine. April 18, 2018 Accreditation Council for Graduate Medical Education. https://psnet.ahrq.gov/issue/physician-well-being Physician and resident well-being is receiving increased attention as an area of focus of the clinical learning environment. This we…

8738. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40183/psn-pdf
      February 02, 2011 - Nurses' work schedule characteristics, nurse staffing, and patient mortality. February 2, 2011 Trinkoff AM, Johantgen M, Storr CL, et al. Nurses' work schedule characteristics, nurse staffing, and patient mortality. Nurs Res. 2011;60(1):1-8. doi:10.1097/NNR.0b013e3181fff15d. https://psnet.ahrq.gov/issue/nurses-wor…

8739. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40407/psn-pdf
      October 04, 2011 - Insights into the climate of safety towards the prevention of falls among hospital staff. October 4, 2011 Black AA, Brauer SG, Bell RAR, et al. Insights into the climate of safety towards the prevention of falls among hospital staff. J Clin Nurs. 2011;20(19-20):2924-30. doi:10.1111/j.1365-2702.2010.03535.x. https:…

8740. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41818/psn-pdf
      July 02, 2014 - Perspective: a business school view of medical interprofessional rounds: transforming rounding groups into rounding teams. July 2, 2014 Bharwani AM, Harris C, Southwick FS. Perspective: a business school view of medical interprofessional rounds: transforming rounding groups into rounding teams. Acad Med. 2012;87(1…