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9081. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43321/psn-pdf
      August 02, 2015 - Costs associated with surgical site infections in Veterans Affairs hospitals. August 2, 2015 Schweizer ML, Cullen JJ, Perencevich E, et al. Costs Associated With Surgical Site Infections in Veterans Affairs Hospitals. JAMA Surg. 2014;149(6):575-81. doi:10.1001/jamasurg.2013.4663. https://psnet.ahrq.gov/issue/costs…

9082. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43575/psn-pdf
      April 22, 2015 - Patient safety challenges in low-income and middle- income countries. April 22, 2015 Steffner KR, McQueen KAK, Gelb AW. Patient safety challenges in low-income and middle-income countries. Curr Opin Anaesthesiol. 2014;27(6):623-9. doi:10.1097/ACO.0000000000000121. https://psnet.ahrq.gov/issue/patient-safety-challe…

9083. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45221/psn-pdf
      July 18, 2016 - When less is better, but physicians are afraid not to intervene. July 18, 2016 Esserman L. When Less Is Better, but Physicians Are Afraid Not to Intervene. JAMA Intern Med. 2016;176(7):888-9. doi:10.1001/jamainternmed.2016.2257. https://psnet.ahrq.gov/issue/when-less-better-physicians-are-afraid-not-intervene Bia…

9084. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838916/psn-pdf
      October 26, 2022 - Falling through the cracks: the invisible hospital cleaning workforce. October 26, 2022 Hacker CE, Debono D, Travaglia J, et al. Falling through the cracks: the invisible hospital cleaning workforce. J Health Organ Manag. 2022;36(8):981-986. doi:10.1108/jhom-02-2022-0035. https://psnet.ahrq.gov/issue/falling-throu…

9085. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74765/psn-pdf
      February 09, 2022 - Whose responsibility is it to address bullying in health care? February 9, 2022 Whose responsibility is it to address bullying in health care? AMA J Ethics. 2022;23(12):E931-936. doi:10.1001/amajethics.2021.931. https://psnet.ahrq.gov/issue/whose-responsibility-it-address-bullying-health-care Disrespectful behavi…

9086. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42617/psn-pdf
      January 24, 2018 - Improving Your Office Testing Process: A Step by Step Guide for Rapid-Cycle Patient Safety and Quality Improvement. January 24, 2018 Rockville, MD: Agency for Healthcare Research and Quality; January 2018. https://psnet.ahrq.gov/issue/improving-your-office-testing-process-step-step-guide-rapid-cycle-patient- safe…

9087. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74128/psn-pdf
      December 01, 2021 - Call to action: addressing pediatric fall safety in ambulatory environments. December 1, 2021 Benning S, Wolfe R, Banes M, et al. Call to action: addressing pediatric fall safety in ambulatory environments. J Pediatr Nurs. 2021;61:372-377. doi:10.1016/j.pedn.2021.09.012. https://psnet.ahrq.gov/issue/call-action-ad…

9088. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37259/psn-pdf
      March 23, 2011 - Using a survey of incident reporting and learning practices to improve organisational learning at a cancer care centre. March 23, 2011 Cooke DL, Dunscombe PB, Lee R. Using a survey of incident reporting and learning practices to improve organisational learning at a cancer care centre. Qual Saf Health Care. 2007;16…

9089. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43189/psn-pdf
      December 15, 2014 - Twitter as a tool to enhance student engagement during an interprofessional patient safety course. December 15, 2014 Mckay M, Sanko JS, Shekhter I, et al. Twitter as a tool to enhance student engagement during an interprofessional patient safety course. J Interprof Care. 2014;28(6):565-7. doi:10.3109/13561820.2014…

9090. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72535/psn-pdf
      December 02, 2020 - Learning from influenza vaccine errors to prepare for COVID-19 vaccination campaigns. December 2, 2020 ISMP Medication Safety Alert! Acute care edition. November 19, 2020;25(23):1-6. https://psnet.ahrq.gov/issue/learning-influenza-vaccine-errors-prepare-covid-19-vaccination-campaigns Safety professionals enco…

9091. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73546/psn-pdf
      July 28, 2021 - A tragic death shows how ERs fail patients who struggle with addiction. July 28, 2021 Pattani A. Health Shots. National Public Radio. July 14, 2021. https://psnet.ahrq.gov/issue/tragic-death-shows-how-ers-fail-patients-who-struggle-addiction Patients with substance abuse disorders face challenges to safe…

9092. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46787/psn-pdf
      October 15, 2018 - Institute for Safe Medication Practices International Mentorship Program. October 15, 2018 Institute for Safe Medication Practices. https://psnet.ahrq.gov/issue/institute-safe-medication-practices-international-mentorship-program Structured interaction with a wide variety of experts and environments enables medica…

9093. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45545/psn-pdf
      October 05, 2016 - How to Improve Electronic Health Record Usability and Patient Safety. October 5, 2016 Philadelphia, PA: Pew Charitable Trusts; September 6, 2016. https://psnet.ahrq.gov/issue/how-improve-electronic-health-record-usability-and-patient-safety The usability of electronic health record (EHR) systems can affect clinici…

9094. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45923/psn-pdf
      April 19, 2017 - Huddles and debriefings: improving communication on labor and delivery. April 19, 2017 McQuaid-Hanson E, Pian-Smith MCM. Huddles and Debriefings: Improving Communication on Labor and Delivery. Anesthesiol Clin. 2017;35(1):59-67. doi:10.1016/j.anclin.2016.09.006. https://psnet.ahrq.gov/issue/huddles-and-debriefings…

9095. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44408/psn-pdf
      April 12, 2017 - Enhancing Surgical Performance: A Primer in Non- technical Skills. April 12, 2017 Flin R, Youngson GG, Yule S. Boca Raton, FL: CRC Press; 2015. ISBN: 9781482246322. https://psnet.ahrq.gov/issue/enhancing-surgical-performance-primer-non-technical-skills Non-technical skill development is gaining attention as a way …

9096. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44704/psn-pdf
      February 09, 2016 - Sensemaking and the co-production of safety: a qualitative study of primary medical care patients. February 9, 2016 Rhodes P, McDonald R, Campbell S, et al. Sensemaking and the co-production of safety: a qualitative study of primary medical care patients. Sociol Health Illn. 2016;38(2):270-285. doi:10.1111/1467- 9…

9097. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73450/psn-pdf
      June 30, 2021 - Decision Making in Emergency Medicine: Biases, Errors and Solutions. June 30, 2021 Raz M, Pouryahya P, eds. Singapore; Springer Nature Singapore Pte Ltd; 2021. ISBN 9789811601422. https://psnet.ahrq.gov/issue/decision-making-emergency-medicine-biases-errors-and-solutions Decision making is vulnerable to huma…

9098. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74048/psn-pdf
      November 10, 2021 - Causes of use errors in ventilation devices--systematic review. November 10, 2021 Coldewey B, Diruf A, Röhrig R, et al. Causes of use errors in ventilation devices - systematic review. Appl Ergon. 2021;98:103544. doi:10.1016/j.apergo.2021.103544. https://psnet.ahrq.gov/issue/causes-use-errors-ventilation-devices-s…

9099. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848827/psn-pdf
      May 10, 2023 - TQIP Mortality Reporting System Case Reports. May 10, 2023 ACS TQIP Mortality Reporting System Writing Group. J Trauma Acute Care Surg. 2023. https://psnet.ahrq.gov/issue/tqip-mortality-reporting-system-case-reports Anonymous case reporting provides opportunities to examine unexpected patient harm instances to pin…

9100. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35672/psn-pdf
      June 28, 2010 - How many hospital pharmacy medication dispensing errors go undetected? June 28, 2010 Cina J, Gandhi TK, Churchill WW, et al. How many hospital pharmacy medication dispensing errors go undetected? Jt Comm J Qual Patient Saf. 2006;32(2):73-80. https://psnet.ahrq.gov/issue/how-many-hospital-pharmacy-medication-dispen…