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8861. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43008/psn-pdf
      November 21, 2014 - Understanding safety culture in long-term care: a case study. November 21, 2014 Halligan MH, Zecevic A, Kothari AR, et al. Understanding safety culture in long-term care: a case study. J Patient Saf. 2014;10(4):192-201. doi:10.1097/PTS.0b013e31829d4ae7. https://psnet.ahrq.gov/issue/understanding-safety-culture-lon…

8862. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39278/psn-pdf
      March 05, 2010 - To ask or not to ask?: the results of a formative assessment of a video empowering patients to ask their health care providers to perform hand hygiene. March 5, 2010 Garcia-Williams A; Brinsley-Rainisch K; Schillie S; Sinkowitz-Cochran R. https://psnet.ahrq.gov/issue/ask-or-not-ask-results-formative-assessment-vid…

8863. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47722/psn-pdf
      January 23, 2019 - Opening the Door to Change. NHS Safety Culture and the Need for Transformation. January 23, 2019 Newcastle upon Tyne, UK: Care Quality Commission; December 2018. https://psnet.ahrq.gov/issue/opening-door-change-nhs-safety-culture-and-need-transformation The term never events was originally coined to describe rare,…

8864. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48072/psn-pdf
      June 19, 2019 - Independent double checks: worth the effort if used judiciously and properly. June 19, 2019 ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24:1-7. https://psnet.ahrq.gov/issue/independent-double-checks-worth-effort-if-used-judiciously-and-properly Independent double checks can reduce risk of human …

8865. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48111/psn-pdf
      July 10, 2019 - Medication Safety in Key Action Areas. July 10, 2019 Geneva, Switzerland: World Health Organization; 2019. https://psnet.ahrq.gov/issue/medication-safety-key-action-areas Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores key areas of concern that require act…

8866. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73238/psn-pdf
      May 12, 2021 - Medical Residents and Burnout May 12, 2021 Coverdale J, West CP, Roberts LW, eds. Acad Med. 2021;96(5):611-769;e14-e21. https://psnet.ahrq.gov/issue/medical-residents-and-burnout Medical training is a demanding experience that impacts a learner’s ability to provide safe care, cope, and remain healthy. This is…

8867. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43898/psn-pdf
      February 11, 2015 - Special Section on Patient Safety and Quality in Healthcare. February 11, 2015 Andersen HB, Lipczak H, Borch-Johnsen K, eds. Cogn Technol Work. 2015;17:1-155. https://psnet.ahrq.gov/issue/special-section-patient-safety-and-quality-healthcare Articles in this special issue explore patient safety from a sociotechnic…

8868. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34129/psn-pdf
      January 16, 2019 - WHO Patient Safety. January 16, 2019 World Health Organization. https://psnet.ahrq.gov/issue/who-patient-safety Reducing accidents and the risk of error requires a significant and sustained response at national and global levels. With this in mind, the World Health Organization and its partners launched the World …

8869. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34748/psn-pdf
      March 07, 2005 - Reducing Adverse Drug Events. March 7, 2005 Leape LL, Kabcenell A, Berwick DM et al. Boston, MA: Institute for Healthcare Improvement; 1998. https://psnet.ahrq.gov/issue/reducing-adverse-drug-events This application-oriented book provides the results of the Institute for Healthcare Improvement (IHI) Breakthrough S…

8870. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40440/psn-pdf
      July 02, 2014 - Residents' reflections on quality improvement: temporal stability and associations with preventability of adverse patient events. July 2, 2014 Wittich CM, Reed DA, Drefahl MM, et al. Residents' reflections on quality improvement: temporal stability and associations with preventability of adverse patient events. Ac…

8871. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72827/psn-pdf
      March 10, 2021 - Coronavirus Commission for Safety and Quality in Nursing Homes. March 10, 2021 Centers for Medicare and Medicaid Services. McLean, VA: MITRE Corporation; September 2020. https://psnet.ahrq.gov/issue/coronavirus-commission-safety-and-quality-nursing-homes Nursing homes have been confronted with numerous …

8872. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38614/psn-pdf
      February 15, 2011 - Effect of a pharmacist on adverse drug events and medication errors in outpatients with cardiovascular disease. February 15, 2011 Murray MD, Ritchey ME, Wu J, et al. Effect of a pharmacist on adverse drug events and medication errors in outpatients with cardiovascular disease. Arch Intern Med. 2009;169(8):757-63. …

8873. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44126/psn-pdf
      May 13, 2015 - SAFER Electronic Health Records: Safety Assurance Factors for EHR Resilience. May 13, 2015 Sittig DF, Singh H, eds. Waretown, NJ: Apple Academic Press; 2015. ISBN: 9781771881173. https://psnet.ahrq.gov/issue/safer-electronic-health-records-safety-assurance-factors-ehr-resilience Implementation of electronic health…

8874. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50822/psn-pdf
      January 22, 2020 - Nurses' sleep, work hours, and patient care quality, and safety January 22, 2020 Stimpfel AW, Fatehi F, Kovner C. Sleep Health. 2020;6(3):314-320. https://psnet.ahrq.gov/issue/nurses-sleep-work-hours-and-patient-care-quality-and-safety Research provides evidence that sleep deprivation among nurses is a threat to p…

8875. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36226/psn-pdf
      August 30, 2006 - Framework for a High Performance Health System for the United States. August 30, 2006 Mongan JJ. New York, NY; The Commonwealth Fund: 2006. https://psnet.ahrq.gov/issue/framework-high-performance-health-system-united-states This report calls for providing "safe, well-coordinated, accessible, and efficient" care th…

8876. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43335/psn-pdf
      July 09, 2014 - Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. July 9, 2014 Tjia I, Rampersad S, Varughese AM, et al. Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. Anesth Analg. 2014;119(1):122-136. doi:10.1213/ANE.0000000000000266. https://psnet.ahrq.gov/is…

8877. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36615/psn-pdf
      January 14, 2011 - The Patient Safety and Quality Improvement Act of 2005: provisions and potential opportunities. January 14, 2011 Liang BA, Riley W, Rutherford W, et al. The Patient Safety and Quality Improvement Act of 2005: Provisions and Potential Opportunities. American Journal of Medical Quality. 2007;22(1). doi:10.1177/10628…

8878. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42677/psn-pdf
      July 16, 2015 - Using "near misses" analysis to prevent wrong-site surgery. July 16, 2015 Yoon RS, Alaia MJ, Hutzler LH, et al. Using "near misses" analysis to prevent wrong-site surgery. J Healthc Qual. 2015;37(2):126-32. doi:10.1111/jhq.12037. https://psnet.ahrq.gov/issue/using-near-misses-analysis-prevent-wrong-site-surgery B…

8879. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39481/psn-pdf
      September 29, 2017 - The natural lifespan of a safety policy: violations and system migration in anaesthesia. September 29, 2017 Maurice G de S, Auroy Y, Vincent CA, et al. The natural lifespan of a safety policy: violations and system migration in anaesthesia. Qual Saf Health Care. 2010;19(4):327-31. doi:10.1136/qshc.2008.029959. htt…

8880. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36040/psn-pdf
      June 21, 2006 - Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant de multiples erreurs dans un service de douleur aigue]. June 21, 2006 Syed S; Paul JE; Hueftlein M; Kampf M; McLean RF. https://psnet.ahrq.gov/issue/morphine-overdose-error-propagation-acute-pain-service-une-surdo…