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9361. 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…

9362. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44848/psn-pdf
      April 22, 2016 - Ambulatory medication reconciliation: using a collaborative approach to process improvement at an academic medical center. April 22, 2016 Keogh C, Kachalia A, Fiumara K, et al. Ambulatory Medication Reconciliation: Using a Collaborative Approach to Process Improvement at an Academic Medical Center. Jt Comm J Qual …

9363. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45025/psn-pdf
      May 04, 2016 - Reducing prognostic errors: a new imperative in quality healthcare. May 4, 2016 Khullar D, Jena AB. Reducing prognostic errors: a new imperative in quality healthcare. BMJ. 2016;352:i1417. doi:10.1136/bmj.i1417. https://psnet.ahrq.gov/issue/reducing-prognostic-errors-new-imperative-quality-healthcare This comment…

9364. 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…

9365. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35598/psn-pdf
      July 10, 2008 - Residents report on adverse events and their causes. July 10, 2008 Jagsi R, Kitch BT, Weinstein DF, et al. Residents report on adverse events and their causes. Arch Intern Med. 2005;165(22):2607-13. https://psnet.ahrq.gov/issue/residents-report-adverse-events-and-their-causes This survey demonstrated that more tha…

9366. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37275/psn-pdf
      December 23, 2011 - Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data. December 23, 2011 Nebeker JR, Yarnold PR, Soltysik RC, et al. Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data. Med Care. 2007;45(10 Supl 2):S81-8. …

9367. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38326/psn-pdf
      January 14, 2009 - Results of a medication reconciliation survey from the 2006 Society of Hospital Medicine national meeting. January 14, 2009 Clay BJ, Halasyamani L, Stucky ER, et al. Results of a medication reconciliation survey from the 2006 Society of Hospital Medicine national meeting. J Hosp Med. 2008;3(6). doi:10.1002/jhm.370.…

9368. 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 …

9369. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47381/psn-pdf
      April 03, 2019 - The role of the patient in patient safety: what can we learn from healthcare's history? April 3, 2019 Leistikow I, Huisman F. The role of the patient in patient safety: What can we learn from healthcare's history? J Patient Saf Risk Manag. 2018;23(4):139-141. doi:10.1177/2516043518791051. https://psnet.ahrq.gov/is…

9370. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866118/psn-pdf
      June 12, 2024 - Factors Affecting the Delivery of Safe Care in Midwifery Units. June 12, 2024 Maternity and Newborn Safety Investigations Programme. Newcastle Upon Tyne, UK: Care Quality Commission; May 2024. https://psnet.ahrq.gov/issue/factors-affecting-delivery-safe-care-midwifery-units Safe maternal care is a challenge world…

9371. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41985/psn-pdf
      October 26, 2016 - Legislative Report to the General Assembly: Adverse Event Reporting. October 26, 2016 Pino R, Furniss WH, Mueller L, Olson JC. Hartford, CT: Connecticut Department of Public Health; October 2016. https://psnet.ahrq.gov/issue/legislative-report-general-assembly-adverse-event-reporting This annual publication provi…

9372. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50709/psn-pdf
      December 04, 2019 - Cognitive engineering to improve patient safety and outcomes in cardiothoracic surgery December 4, 2019 Zenati MA, Kennedy-Metz L, Dias RD. Cognitive Engineering to Improve Patient Safety and Outcomes in Cardiothoracic Surgery. Semin Thorac Cardiovasc Surg. 2019. doi:10.1053/j.semtcvs.2019.10.011. https://psnet.ah…

9373. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836835/psn-pdf
      March 30, 2022 - Bias in mental health diagnosis gets in the way of treatment. March 30, 2022 Garb HN. Psyche. March 22, 2022. https://psnet.ahrq.gov/issue/bias-mental-health-diagnosis-gets-way-treatment A wide array of biases can affect clinical judgement and contribute to diagnostic error. This article discusses the impact of i…

9374. 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…

9375. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44900/psn-pdf
      April 22, 2016 - When a surgical colleague makes an error. April 22, 2016 Antiel RM, Blinman TA, Rentea RM, et al. When a Surgical Colleague Makes an Error. Pediatrics. 2016;137(3):e20153828. doi:10.1542/peds.2015-3828. https://psnet.ahrq.gov/issue/when-surgical-colleague-makes-error Physicians have become more comfortable with re…

9376. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41648/psn-pdf
      September 30, 2012 - Using an objective structured clinical examination to test adherence to Joint Commission National Patient Safety Goal–associated behaviors. September 30, 2012 Pernar LIM, Shaw T, Pozner CN, et al. Using an Objective Structured Clinical Examination to test adherence to Joint Commission National Patient Safety Goal-…

9377. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42625/psn-pdf
      November 08, 2013 - Miscount incidents: a novel approach to exploring risk factors for unintentionally retained surgical items. November 8, 2013 Judson TJ, Howell MD, Guglielmi C, et al. Miscount incidents: a novel approach to exploring risk factors for unintentionally retained surgical items. Jt Comm J Qual Patient Saf. 2013;39(10):4…

9378. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47067/psn-pdf
      May 16, 2018 - Senior staff safety rounds: a commitment to ensure safety is the top priority. May 16, 2018 O'Connell RT, Ivy ME. NEJM Catalyst. May 1, 2018. https://psnet.ahrq.gov/issue/senior-staff-safety-rounds-commitment-ensure-safety-top-priority Leadership participation at the front lines can drive safety improvement work. …

9379. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43768/psn-pdf
      December 10, 2014 - Accountability in nursing practice: why it is important for patient safety. December 10, 2014 Battié R, Steelman VM. Accountability in nursing practice: why it is important for patient safety. AORN J. 2014;100(5):537-541. doi:10.1016/j.aorn.2014.08.008. https://psnet.ahrq.gov/issue/accountability-nursing-practice-…

9380. 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…