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9141. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35809/psn-pdf
      February 25, 2015 - Stories from the sharp end: case studies in safety improvement. February 25, 2015 McCarthy D; Blumenthal D. Milbank Q. 2006;84(1):165-200 https://psnet.ahrq.gov/issue/stories-sharp-end-case-studies-safety-improvement This study shares the efforts of six different health care organizations in implementing intervent…

9142. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38938/psn-pdf
      July 26, 2023 - ISMP's List of Confused Drug Names. July 26, 2023 Horsham, PA; Institute for Safe Medication Practices: July 2023. https://psnet.ahrq.gov/issue/ismps-list-confused-drug-names Drawing on information gathered from the ISMP Medication Errors Reporting Program, this fact sheet provides a comprehensive list of commonly…

9143. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34663/psn-pdf
      December 23, 2008 - Improving the quality of health care: who will lead? December 23, 2008 Becher EC, Chassin MR. Improving the quality of health care: who will lead? Health Aff (Millwood). 2001;20(5):164-79. https://psnet.ahrq.gov/issue/improving-quality-health-care-who-will-lead In this review, Becher and Chassin discuss the persis…

9144. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37809/psn-pdf
      November 21, 2016 - Partnering with Patients and Families to Design a Patient- and Family-Centered Health Care System: Recommendations and Promising Practices. November 21, 2016 Johnson B, Abraham M, Conway J, et al. Bethesda, MD: Institute for Family-Centered Care; April 2008. https://psnet.ahrq.gov/issue/partnering-patients-and-fam…

9145. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45070/psn-pdf
      October 03, 2017 - When There's Harm in the Hospital: Can Transparency Replace "Deny and Defend"? October 3, 2017 National Health Policy Forum. Washington, DC: George Washington University. March 11, 2016. https://psnet.ahrq.gov/issue/when-theres-harm-hospital-can-transparency-replace-deny-and-defend This report provides the insight…

9146. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846168/psn-pdf
      March 15, 2023 - Now is the time to routinely ask patients about safety. March 15, 2023 Gandhi TK. Now Is the Time to Routinely Ask Patients About Safety. Jt Comm J Qual Patient Saf. 2023;49(4):235-236. doi:10.1016/j.jcjq.2023.01.009. https://psnet.ahrq.gov/issue/now-time-routinely-ask-patients-about-safety Safety event reporting …

9147. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865598/psn-pdf
      April 17, 2024 - Guardians of grafts: reducing medication errors in transplant recipients. April 17, 2024 ISMP Medication Safety Alert! Acute care. April 4, 2024;29(7):1-4. https://psnet.ahrq.gov/issue/guardians-grafts-reducing-medication-errors-transplant-recipients Safe medication therapy for transplant patients is complex and h…

9148. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48043/psn-pdf
      October 01, 2023 - Health Services Safety Investigations Body. October 1, 2023 Lytchett House, 13 Freeland Park, Wareham Road, Poole, Dorset, BH16 6FA. https://psnet.ahrq.gov/issue/health-services-safety-investigations-body Independent investigations examine system weaknesses in health care to inform improvement, reduce risk, and pr…

9149. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836920/psn-pdf
      April 13, 2022 - Family support role in hospital rapid response teams: a scoping review. April 13, 2022 Howlett O, Gleeson R, Jackson L, et al. Family support role in hospital rapid response teams: a scoping review. JBI Evid Synth. 2022;20(8):2001-2024. doi:10.11124/jbies-21-00189. https://psnet.ahrq.gov/issue/family-support-role-…

9150. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43677/psn-pdf
      November 19, 2014 - Reporting and Learning Systems for Medication Errors: The Role of Pharmacovigilance Centres. November 19, 2014 Bencheikh SR, Cousins D, Benabdallah G, et al. Geneva, Switzerland: World Health Organization; October 2014. ISBN: 9789241507943. https://psnet.ahrq.gov/issue/reporting-and-learning-systems-medication-err…

9151. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46483/psn-pdf
      October 04, 2017 - Fall Prevention in Hospitals Training Program. October 4, 2017 Rockville, MD: Agency for Healthcare Research and Quality; 2017. https://psnet.ahrq.gov/issue/fall-prevention-hospitals-training-program Falls are a primary focus of quality and patient safety improvement efforts in hospitals. This training program pro…

9152. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37398/psn-pdf
      March 28, 2012 - A facilitated survey instrument captures significantly more anesthesia events than does traditional voluntary event reporting. March 28, 2012 Oken A, Rasmussen MD, Slagle JM, et al. A facilitated survey instrument captures significantly more anesthesia events than does traditional voluntary event reporting. Anesth…

9153. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50705/psn-pdf
      January 01, 2020 - Closing the loop with ambulatory staff on safety reports. December 4, 2019 Williams S, Fiumara K, Kachalia A, et al. Closing the Loop with Ambulatory Staff on Safety Reports. Jt Comm J Qual Saf. 2020;46(1):44-50. doi:10.1016/j.jcjq.2019.09.009. https://psnet.ahrq.gov/issue/closing-loop-ambulatory-staff-safety-repor…

9154. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45881/psn-pdf
      March 15, 2017 - CE: nursing's evolving role in patient safety. March 15, 2017 Kowalski SL, Anthony M. CE: Nursing's Evolving Role in Patient Safety. Am J Nurs. 2017;117(2):34-48. doi:10.1097/01.NAJ.0000512274.79629.3c. https://psnet.ahrq.gov/issue/ce-nursings-evolving-role-patient-safety Nursing is a key component of patient care…

9155. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45987/psn-pdf
      April 26, 2017 - Using simulation to prepare nursing staff for the move to a new building. April 26, 2017 Knippa S, Senecal P-A. Using Simulation to Prepare Nursing Staff for the Move to a New Building. J Nurses Prof Dev. 2017;33(2):E1-E5. doi:10.1097/NND.0000000000000329. https://psnet.ahrq.gov/issue/using-simulation-prepare-nurs…

9156. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46791/psn-pdf
      May 23, 2018 - Medication Safety Dashboard. May 23, 2018 National Health Service. https://psnet.ahrq.gov/issue/medication-safety-dashboard Data surveillance and transparency are core to measuring and informing improvement efforts. This website provides detailed data that links ambulatory care prescribing activity to National Hea…

9157. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44540/psn-pdf
      September 30, 2015 - The bare minimum: the reality of global anaesthesia and patient safety. September 30, 2015 McQueen K, Coonan T, Ottaway A, et al. The Bare Minimum: The Reality of Global Anaesthesia and Patient Safety. World J Surg. 2015;39(9):2153-60. doi:10.1007/s00268-015-3101-x. https://psnet.ahrq.gov/issue/bare-minimum-realit…

9158. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45621/psn-pdf
      November 09, 2016 - Impact of age on anaesthesiologists' competence: a narrative review. November 9, 2016 Giacalone M, Zaouter C, Mion S, et al. Impact of age on anaesthesiologists' competence: A narrative review. Eur J Anaesthesiol. 2016;33(11):787-793. https://psnet.ahrq.gov/issue/impact-age-anaesthesiologists-competence-narrative-…

9159. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44014/psn-pdf
      March 20, 2019 - Patient Centered Medical Home Resource Center: Quality and Safety. March 20, 2019 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/patient-centered-medical-home-resource-center-quality-and-safety The Patient Centered Medical Home (PCMH) concept reorganizes primary care services to ensure th…

9160. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46854/psn-pdf
      June 20, 2018 - FDA Safety Communication: recommendations to reduce surgical fires and related patient injury. June 20, 2018 MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. May 29, 2018. https://psnet.ahrq.gov/issue/fda-safety-communication-recommendations-reduce-surgical-fires-and-related- patient-inju…