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8741. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37332/psn-pdf
      November 14, 2007 - Is Our Pharmacy Meeting Patients' Needs? A Pharmacy Health Literacy Assessment Tool User's Guide. November 14, 2007 Jacobson KL, Gazmararian JA, Kripalani S, et al. Rockville, MD: Agency for Healthcare Research and Quality. October 2007. AHRQ Publication No. 07-0051. https://psnet.ahrq.gov/issue/our-pharmacy-meeti…

8742. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35116/psn-pdf
      April 06, 2011 - Crises in clinical care: an approach to management. April 6, 2011 Runciman WB. Crises in clinical care: an approach to management. Quality and Safety in Health Care. 2005;14(3). doi:10.1136/qshc.2004.012856. https://psnet.ahrq.gov/issue/crises-clinical-care-approach-management This commentary discusses the many fa…

8743. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44487/psn-pdf
      September 23, 2015 - Patient safety and quality improvement: terminology. September 23, 2015 Pereira-Argenziano L, Levy FH. Patient Safety and Quality Improvement: Terminology. Pediatr Rev. 2015;36(9):403-11; quiz 412-3. doi:10.1542/pir.36-9-403. https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-terminology To Err Is…

8744. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45808/psn-pdf
      December 19, 2017 - A concept analysis of systems thinking. December 19, 2017 Stalter AM, Phillips JM, Ruggiero JS, et al. A Concept Analysis of Systems Thinking. Nurs Forum. 2017;52(4):323-330. doi:10.1111/nuf.12196. https://psnet.ahrq.gov/issue/concept-analysis-systems-thinking Systems thinking focuses on enabling an organization t…

8745. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35477/psn-pdf
      November 16, 2005 - A Safer Place for Patients: Learning to Improve Patient Safety. November 16, 2005 National Audit Office. London UK: The Stationery Office; 2005. ISBN 0102933448. https://psnet.ahrq.gov/issue/safer-place-patients-learning-improve-patient-safety This report details the current state of patient safety in the National…

8746. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45429/psn-pdf
      December 19, 2016 - ONC Health IT Certification Program: Enhanced Oversight and Accountability. November 30, 2016 Office of the National Coordinator for Health Information Technology; ONC; Health and Human Services; HHS. https://psnet.ahrq.gov/issue/onc-health-it-certification-program-enhanced-oversight-and-accountability Requiremen…

8747. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46469/psn-pdf
      October 25, 2017 - RxAwareness. October 25, 2017 Centers for Disease Control and Prevention; CDC. https://psnet.ahrq.gov/issue/rxawareness The opioid crisis is a persisting patient safety problem. One approach to prevent misuse of opioids is to raise awareness of the addictive nature of the medication. This national campaign enlists…

8748. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39829/psn-pdf
      January 09, 2025 - Hospital Reporting Program: Annual Summary. January 9, 2025 Portland, OR: Oregon Patient Safety Commission. https://psnet.ahrq.gov/issue/hospital-reporting-program-annual-summary This site provides data and analysis from two Oregon Patient Safety Commission patient safety initiatives: the Patient Safety Reporting …

8749. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72754/psn-pdf
      February 17, 2021 - Telehealth in the COVID-19 era: a balancing act to avoid harm. February 17, 2021 Reeves JJ, Ayers JW, Longhurst CA. Telehealth in the COVID-19 Era: a balancing act to avoid harm. J Med Internet Res. 2021;23(2):e24785. doi:10.2196/24785. https://psnet.ahrq.gov/issue/telehealth-covid-19-era-balancing-act-avoid-harm …

8750. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45413/psn-pdf
      September 21, 2016 - A piece of my mind. Snakes on a dock. September 21, 2016 Detsky AS. Snakes on a Dock. JAMA. 2016;316(10):1043-4. doi:10.1001/jama.2016.5179. https://psnet.ahrq.gov/issue/piece-my-mind-snakes-dock Storytelling has been advocated as a strategy to teach and augment awareness in patient safety. In this commentary, the…

8751. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45379/psn-pdf
      August 17, 2016 - A piece of my mind. How many have you done? August 17, 2016 Reisman A. A PIECE OF MY MIND. How Many Have You Done? JAMA. 2016;316(5):491. doi:10.1001/jama.2016.1996. https://psnet.ahrq.gov/issue/piece-my-mind-how-many-have-you-done This commentary explores transparency in response to patient and family inquiry reg…

8752. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43741/psn-pdf
      December 03, 2014 - Overdiagnosis: how our compulsion for diagnosis may be harming children. December 3, 2014 Coon ER, Quinonez RA, Moyer VA, et al. Overdiagnosis: how our compulsion for diagnosis may be harming children. Pediatrics. 2014;134(5):1013-23. doi:10.1542/peds.2014-1778. https://psnet.ahrq.gov/issue/overdiagnosis-how-our-c…

8753. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73994/psn-pdf
      October 20, 2021 - A culture of safety in EMS systems. October 20, 2021 American College of Emergency Physicians, National Association of Emergency Medical Services.  Ann Emerg Med. 2021;78(3):e37-e57.  https://psnet.ahrq.gov/issue/culture-safety-ems-systems-0 Emergency medical services (EMS) are often provided in stressfu…

8754. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43734/psn-pdf
      January 21, 2015 - Explicit and Standardized Prescription Medicine Instructions. January 21, 2015 Rockville, MD: Agency for Healthcare Research and Quality; December 2014. https://psnet.ahrq.gov/issue/explicit-and-standardized-prescription-medicine-instructions Standardization has been embraced as a strategy to improve health litera…

8755. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37555/psn-pdf
      February 14, 2018 - ACOG Committee Opinion #730: fatigue and patient safety. February 14, 2018 ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2018;131(2):e78- e81. https://psnet.ahrq.gov/issue/acog-committee-opinion-730-fatigue-and-patient-safety This commentary discusses how sleep deprivation affects…

8756. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60808/psn-pdf
      August 12, 2020 - Paediatric International Patient Safety and Quality Community. August 12, 2020 Paediatric International Patient Safety and Quality Community. 525 University Ave, Suite 630, Toronto, Ontario M5G 2L3, Canada. https://psnet.ahrq.gov/issue/paediatric-international-patient-safety-and-quality-community The safety of ch…

8757. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44934/psn-pdf
      February 07, 2023 - National Safety Standards for Invasive Procedures (NatSSIPs2). February 7, 2023 Centre for Perioperative Care. London, UK; January 2023. https://psnet.ahrq.gov/issue/national-safety-standards-invasive-procedures-natssips Patients face risks when undergoing surgery. This revised guidance provides recommendations de…

8758. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41880/psn-pdf
      January 08, 2014 - DOD and VA Health Care: Medication Needs During Transitions May Not Be Managed for All Servicemembers. January 8, 2014 Washington, DC: United States Government Accountability Office; November 2, 2012. Publication GAO-13- 26.   https://psnet.ahrq.gov/issue/dod-and-va-health-care-medication-needs-during-transit…

8759. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47466/psn-pdf
      October 17, 2018 - ASHP guidelines on preventing medication errors in hospitals. October 17, 2018 Billstein-Leber M, Carrillo CJD, Cassano AT, et al. ASHP Guidelines on Preventing Medication Errors in Hospitals. Am J Health-Syst Pharm. 2018;75(19):1493-1517. doi:10.2146/ajhp170811. https://psnet.ahrq.gov/issue/ashp-guidelines-preven…

8760. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35859/psn-pdf
      July 22, 2010 - A multifaceted approach to improve patient safety, prevent medical errors and resolve the professional liability crisis. July 22, 2010 Weinstein L. A multifacited approach to improve patient safety, prevent medical errors and resolve the professional liability crisis. Am J Obstet Gynecol. 2006;194(4):1160-5; discu…