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9281. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50925/psn-pdf
      February 19, 2020 - Report of the Independent Inquiry into the Issues Raised by Paterson. February 19, 2020 James G. House Commons Report 31. Department of Health and Social Care. London, England: Crown Copyright; 2020. ISBN 9781528617284. https://psnet.ahrq.gov/issue/report-independent-inquiry-issues-raised-paterson Shari…

9282. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47555/psn-pdf
      November 14, 2018 - How one hospital improved patient safety in 10 minutes a day. November 14, 2018 van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018. https://psnet.ahrq.gov/issue/how-one-hospital-improved-patient-safety-10-minutes-day Aviation continues to provide inspiration for patient safety innovation. This commentar…

9283. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37525/psn-pdf
      June 14, 2011 - Recommended guidelines for monitoring, reporting, and conducting research on medical emergency team, outreach, and rapid response systems: an Utstein-style scientific statement. June 14, 2011 Peberdy MA, Cretikos MA, Abella BS, et al. Recommended Guidelines for Monitoring, Reporting, and Conducting Research on Me…

9284. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42806/psn-pdf
      January 19, 2014 - Case studies of patient safety research classics to build research capacity in low- and middle-income countries. January 19, 2014 Andermann A, Wu AW, Lashoher A, et al. Case studies of patient safety research classics to build research capacity in low- and middle-income countries. Jt Comm J Qual Patient Saf. 2013;3…

9285. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45316/psn-pdf
      August 31, 2016 - The thinking doctor: clinical decision making in contemporary medicine. August 31, 2016 Trimble M, Hamilton P. The thinking doctor: clinical decision making in contemporary medicine. Clin Med (Lond). 2016;16(4):343-346. doi:10.7861/clinmedicine.16-4-343. https://psnet.ahrq.gov/issue/thinking-doctor-clinical-decisi…

9286. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35182/psn-pdf
      April 11, 2011 - Standard drug concentrations and smart-pump technology reduce continuous-medication-infusion errors in pediatric patients. April 11, 2011 Larsen G, Parker HB, Cash J, et al. Standard drug concentrations and smart-pump technology reduce continuous-medication-infusion errors in pediatric patients. Pediatrics. 2005;1…

9287. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38143/psn-pdf
      February 18, 2011 - A multidisciplinary teamwork training program: The Triad for Optimal Patient Safety (TOPS) experience. February 18, 2011 Sehgal NL, Fox M, Vidyarthi A, et al. A multidisciplinary teamwork training program: the Triad for Optimal Patient Safety (TOPS) experience. J Gen Intern Med. 2008;23(12):2053-7. doi:10.1007/s116…

9288. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60626/psn-pdf
      June 24, 2020 - A nursing home’s 64-day Covid siege: ‘They’re all going to die’. June 24, 2020 Barker K. A nursing home’s 64-day Covid siege: ‘They’re all going to die’. New York Times. 2020;June 10. https://psnet.ahrq.gov/issue/nursing-homes-64-day-covid-siege-theyre-all-going-die This feature story describes the COVID-19 experi…

9289. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40697/psn-pdf
      October 31, 2011 - Real-time automated paging and decision support for critical laboratory abnormalities. October 31, 2011 Etchells E, Adhikari NKJ, Wu RC, et al. Real-time automated paging and decision support for critical laboratory abnormalities. BMJ Qual Saf. 2011;20(11):924-30. doi:10.1136/bmjqs.2010.051110. https://psnet.ahrq.…

9290. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46248/psn-pdf
      October 23, 2018 - Medical errors, malpractice, and defensive medicine: an ill-fated triad. October 23, 2018 Berlin L. Medical errors, malpractice, and defensive medicine: an ill-fated triad. Diagnosis (Berl). 2017;4(3):133-139. doi:10.1515/dx-2017-0007. https://psnet.ahrq.gov/issue/medical-errors-malpractice-and-defensive-medicine-…

9291. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48006/psn-pdf
      May 15, 2019 - Limits on opioid prescribing leave patients with chronic pain vulnerable. May 15, 2019 Rubin R. Limits on Opioid Prescribing Leave Patients With Chronic Pain Vulnerable. JAMA. 2019;321(21):2059-2062. doi:10.1001/jama.2019.5188. https://psnet.ahrq.gov/issue/limits-opioid-prescribing-leave-patients-chronic-pain-vuln…

9292. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43034/psn-pdf
      March 12, 2014 - Implementation of a pediatric rapid response team: experience of the Hospital for Sick Children in Toronto. March 12, 2014 Kukreti V, Gaiteiro R, Mohseni-Bod H. Implementation of a pediatric rapid response team: experience of the Hospital for Sick Children in Toronto. Indian Pediatr. 2014;51(1):11-5. https://psnet…

9293. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34730/psn-pdf
      October 29, 2013 - Medication Errors. 2nd ed. October 29, 2013 Cohen MR, ed. Washington DC: American Pharmacists Association; 2007. https://psnet.ahrq.gov/issue/medication-errors-2nd-ed Cohen, executive director of the Institute for Safe Medication Practices (ISMP), combined 25 years of experience as a leader in medication safety wi…

9294. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866411/psn-pdf
      July 31, 2024 - Simulation to Improve Patient Safety: Getting Started. July 31, 2024 Deutsch ES, Bajaj K. Simulation To Improve Patient Safety: Getting Started. Rockville, MD: Agency for Healthcare Research and Quality; July 2024. Publication No. 24-0055. https://psnet.ahrq.gov/issue/simulation-improve-patient-safety-getting-start…

9295. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43045/psn-pdf
      August 02, 2015 - A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus. August 2, 2015 Alam M, Lee A, Ibrahimi OA, et al. A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a…

9296. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36086/psn-pdf
      June 14, 2011 - Sensemaking of patient safety risks and hazards. June 14, 2011 Battles J, Dixon NM, Borotkanics RJ, et al. Sensemaking of patient safety risks and hazards. Health Serv Res. 2006;41(4 Pt 2):1555-1575. https://psnet.ahrq.gov/issue/sensemaking-patient-safety-risks-and-hazards This commentary discusses the concept of …

9297. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37794/psn-pdf
      February 15, 2011 - Using staff perceptions on patient safety as a tool for improving safety culture in a pediatric hospital system. February 15, 2011 Edwards PJ, Scott T, Richardson P, et al. Using Staff Perceptions on Patient Safety as a Tool for Improving Safety Culture in a Pediatric Hospital System. J Patient Saf. 2009;4(2). doi:…

9298. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46909/psn-pdf
      August 01, 2018 - Guidance on Safe Medical Staffing: Report of a Working Party. August 1, 2018 London, UK: Royal College of Physicians; 2018. ISBN: 9781860167270. https://psnet.ahrq.gov/issue/guidance-safe-medical-staffing-report-working-party Lack of appropriate staffing can diminish the safety and effectiveness of medical service…

9299. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36769/psn-pdf
      June 15, 2011 - Using incident reporting to improve patient safety: a conceptual model. June 15, 2011 Pronovost PJ, Holzmueller CG, Young J, et al. Using Incident Reporting to Improve Patient Safety. J Patient Saf. 2008;3(1). doi:10.1097/pts.0b013e318030ca05. https://psnet.ahrq.gov/issue/using-incident-reporting-improve-patient-s…

9300. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/849126/psn-pdf
      May 17, 2023 - The family's contribution to patient safety. May 17, 2023 Correia T, Martins MM, Barroso F, et al. The family's contribution to patient safety. Nurs Rep. 2023;13(2):634-643. doi:10.3390/nursrep13020056. https://psnet.ahrq.gov/issue/familys-contribution-patient-safety Family involvement in care can have mixed resul…