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9521. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50818/psn-pdf
      January 22, 2020 - Burnout in pediatric residents: three years of national survey January 22, 2020 Kemper KJ, Schwartz A, Wilson PM, et al. Burnout in Pediatric Residents: Three Years of National Survey Data. Pediatrics. 2020;145(1):e20191030. doi:10.1542/peds.2019-1030. https://psnet.ahrq.gov/issue/burnout-pediatric-residents-three…

9522. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45062/psn-pdf
      May 18, 2016 - Opioid Epidemic & Health IT May 18, 2016 Section 4. Health IT Playbook. Office of the National Coordinator for Health Information Technology. https://psnet.ahrq.gov/issue/attacking-opioid-crisis-head-health-it Overdoses of opioid medications are considered an epidemic in the United States. This website provides ac…

9523. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46973/psn-pdf
      June 25, 2018 - Balancing innovation and safety when integrating digital tools into health care. June 25, 2018 Auerbach AD, Neinstein A, Khanna R. Balancing Innovation and Safety When Integrating Digital Tools Into Health Care. Ann Intern Med. 2018;168(10):733-734. doi:10.7326/M17-3108. https://psnet.ahrq.gov/issue/balancing-inno…

9524. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42179/psn-pdf
      April 10, 2013 - Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes. April 10, 2013 Bowie P, Skinner J, de Wet C. Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitud…

9525. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73706/psn-pdf
      September 15, 2021 - A meta-review of methods of measuring and monitoring safety in primary care. September 15, 2021 O’Connor P, Madden C, O’Dowd E, et al. A meta-review of methods of measuring and monitoring safety in primary care. Int J Qual Health Care. 2021;33(3):mzab117. doi:10.1093/intqhc/mzab117. https://psnet.ahrq.gov/issue/me…

9526. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840163/psn-pdf
      November 16, 2022 - Deep Dive: Racial and Ethnic Disparities in Health and Healthcare. November 16, 2022 Plymouth Meeting, PA: ECRI and the Institute for Safe Medication Practices; 2022. https://psnet.ahrq.gov/issue/deep-dive-racial-and-ethnic-disparities-health-and-healthcare Racist behavior directed at either patients or clinicians…

9527. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43456/psn-pdf
      October 03, 2017 - Veterans' Access to Care through Choice, Accountability, and Transparency Act of 2014. October 3, 2017 HR 3230, 113th Congress: 2014. https://psnet.ahrq.gov/issue/veterans-access-care-through-choice-accountability-and-transparency-act- 2014 The Veterans Affairs (VA) health system has both achieved success and str…

9528. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34652/psn-pdf
      March 04, 2011 - Epidemiology of medical error. March 4, 2011 Weingart SN, Wilson R, Gibberd RW, et al. Epidemiology of medical error. BMJ. 2000;320(7237):774-7. https://psnet.ahrq.gov/issue/epidemiology-medical-error This article summarizes the epidemiology of medical errors. The authors provide findings from benchmark studies to…

9529. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46733/psn-pdf
      February 14, 2018 - Randomized controlled evaluation of an insulin pen storage policy. February 14, 2018 Gibbs HG, McLernon T, Call R, et al. Randomized controlled evaluation of an insulin pen storage policy. Am J Health Syst Pharm. 2017;74(24):2054-2059. doi:10.2146/ajhp160348. https://psnet.ahrq.gov/issue/randomized-controlled-eval…

9530. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43565/psn-pdf
      March 22, 2016 - The role of failure mode and effects analysis in health care. March 22, 2016 Fibuch E, Ahmed A. The role of failure mode and effects analysis in health care. Physician Exec. 2014;40(4):28-32. https://psnet.ahrq.gov/issue/role-failure-mode-and-effects-analysis-health-care Failure mode and effects analysis (FMEA) h…

9531. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34676/psn-pdf
      December 23, 2008 - Driving improvement in patient care: lessons from Toyota. December 23, 2008 Thompson DN, Wolf GA, Spear SJ. Driving improvement in patient care: lessons from Toyota. J Nurs Adm. 2003;33(11):585-595. https://psnet.ahrq.gov/issue/driving-improvement-patient-care-lessons-toyota Representatives from University of Pit…

9532. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43979/psn-pdf
      April 29, 2015 - The Report of the Morecambe Bay Investigation. April 29, 2015 Kirkup B. London, UK: The Stationery Office; 2015. ISBN: 9780108561306. https://psnet.ahrq.gov/issue/report-morecambe-bay-investigation Sharing information about large-scale investigations into failures can provide insights on factors that contribute to…

9533. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41341/psn-pdf
      June 01, 2012 - A systematic proactive risk assessment of hazards in surgical wards: a quantitative study. June 1, 2012 Anderson O, Brodie A, Vincent CA, et al. A systematic proactive risk assessment of hazards in surgical wards: a quantitative study. Ann Surg. 2012;255(6):1086-92. doi:10.1097/SLA.0b013e31824f5f36. https://psnet.…

9534. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37511/psn-pdf
      February 06, 2008 - Validity of retrospective review of medical records as a means of identifying adverse events: comparison between medical records and accident reports. February 6, 2008 Kobayashi M, Ikeda S, Kitazawa N, et al. Validity of retrospective review of medical records as a means of identifying adverse events: comparison b…

9535. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46764/psn-pdf
      March 28, 2018 - The Report of the Short Life Working Group on Reducing Medication-related Harm. March 28, 2018 Department of Health and Social Care. London, England: Crown Publishing; February 2018. https://psnet.ahrq.gov/issue/report-short-life-working-group-reducing-medication-related-harm Medication errors are a prominent chal…

9536. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34742/psn-pdf
      July 20, 2016 - Culture at Work in Aviation and Medicine: National, Organizational, and Professional Influences. July 20, 2016 Helmreich RL, Merritt AC. Brookfield, VT: Ashgate; 1998. ISBN: 9780291398536. https://psnet.ahrq.gov/issue/culture-work-aviation-and-medicine-national-organizational-and-professional- influences This boo…

9537. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42928/psn-pdf
      September 19, 2016 - Supporting second victims of patient safety events: shouldn't these communications be covered by legal privilege? September 19, 2016 de Wit ME, Marks CM, Natterman JP, et al. Supporting second victims of patient safety events: shouldn't these communications be covered by legal privilege? J Law Med Ethics. 2013;41(…

9538. 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…

9539. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44627/psn-pdf
      May 30, 2016 - Exploring attitudes and opinions of pharmacists toward delivering prescribing error feedback: a qualitative case study using focus group interviews. May 30, 2016 Lloyd M, Watmough SD, O'Brien S, et al. Exploring attitudes and opinions of pharmacists toward delivering prescribing error feedback: A qualitative case …

9540. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43955/psn-pdf
      December 04, 2016 - For Colorado mom, story of daughter's hospital death is key to others' safety. December 4, 2016 Daley J. Colorado Public Radio. February 17, 2015. https://psnet.ahrq.gov/issue/colorado-mom-story-daughters-hospital-death-key-others-safety Patient and family stories of harm are increasingly promoted as a strategy to…