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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74042/psn-pdf
    November 03, 2021 - An Investigation into the Death of Baby J at University Hospitals Bristol and Weston NHS Foundation Trust. November 3, 2021 Manchester, UK: Parliamentary and Health Service Ombudsman; October 2021. https://psnet.ahrq.gov/issue/investigation-death-baby-j-university-hospitals-bristol-and-weston-nhs- foundation-trust…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34715/psn-pdf
    February 18, 2011 - Continuous improvement as an ideal in health care. February 18, 2011 Berwick D. Continuous improvement as an ideal in health care. New Engl J Med. 1989;320(1):53-56. https://psnet.ahrq.gov/issue/continuous-improvement-ideal-health-care Two approaches to improving quality in health care are illustrated in this artic…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42790/psn-pdf
    December 04, 2013 - Patients do not always complain when they are dissatisfied: implications for service quality and patient safety. December 4, 2013 Howard M, Fleming ML, Parker E. Patients do not always complain when they are dissatisfied: implications for service quality and patient safety. J Patient Saf. 2013;9(4):224-31. doi:10…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42645/psn-pdf
    October 09, 2013 - Eliminating CAUTI: Interim Data Report: A National Patient Safety Imperative. October 9, 2013 Rockville, MD: Agency for Healthcare Research and Quality; July 2013. AHRQ Publication No. 13-0071- EF. https://psnet.ahrq.gov/issue/eliminating-cauti-interim-data-report-national-patient-safety-imperative This report pr…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867632/psn-pdf
    February 26, 2025 - Instruments for patient safety assessment: a scoping review. February 26, 2025 Nunes E, Sirtoli F, Lima E, et al. Instruments for patient safety assessment: a scoping review. Healthcare. 2024;12(20):2075. doi:10.3390/healthcare12202075. https://psnet.ahrq.gov/issue/instruments-patient-safety-assessment-scoping-rev…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60963/psn-pdf
    September 30, 2020 - Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: a real-time observational study. September 30, 2020 Morreel S, Philips H, Verhoeven V. Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: a real-time observational study. PLoS One. 2020;…
  7. 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…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44794/psn-pdf
    May 21, 2019 - Medical Device Use Error: Root Cause Analysis. May 21, 2019 Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790. https://psnet.ahrq.gov/issue/medical-device-use-error-root-cause-analysis Applying human factors engineering to examine mistakes associated with medical device use can lead …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73922/psn-pdf
    October 06, 2021 - Leading causes of anesthesia-related liability claims in ambulatory surgery centers. October 6, 2021 Ranum D, Beverly A, Shapiro FE, et al. Leading causes of anesthesia-related liability claims in ambulatory surgery centers. J Patient Saf. 2021;17(7):513-521. doi:10.1097/pts.0000000000000431. https://psnet.ahrq.go…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46019/psn-pdf
    April 26, 2017 - Certified registered nurse anesthetist perceptions of factors impacting patient safety. April 26, 2017 McMullan SP, Thomas-Hawkins C, Shirey MR. Certified Registered Nurse Anesthetist Perceptions of Factors Impacting Patient Safety. Nurs Adm Q. 2017;41(1):56-69. https://psnet.ahrq.gov/issue/certified-registered-nu…
  11. 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…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852286/psn-pdf
    August 09, 2023 - Guidelines on Human Factors in Critical Situations 2023. August 9, 2023 Bijok B, Jaulin F, Picard J, et al. Guidelines on human factors in critical situations 2023. Anaesth Crit Care Pain Med. 2023;42(4):101262. doi:10.1016/j.accpm.2023.101262. https://psnet.ahrq.gov/issue/guidelines-human-factors-critical-situatio…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838025/psn-pdf
    September 07, 2022 - Opportunities to mine EHRs for malpractice risk management and patient safety. September 7, 2022 Adler-Milstein J, Sarkar U, Wachter RM. Opportunities to mine EHRs for malpractice risk management and patient safety. J Patient Saf Risk Manag. 2022;27(4):160-162. doi:10.1177/25160435221097422. https://psnet.ahrq.gov…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50554/psn-pdf
    October 16, 2019 - Adverse events in the operating room: definitions, prevalence, and characteristics. A systematic review. October 16, 2019 Jung JJ, Elfassy J, Jüni P, et al. Adverse Events in the Operating Room: Definitions, Prevalence, and Characteristics. A Systematic Review. World J Surg. 2019;43(10):2379-2392. doi:10.1007/s0026…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863221/psn-pdf
    February 28, 2024 - Using artificial intelligence to improve primary care for patients and clinicians. February 28, 2024 Sarkar U, Bates DW. Using artificial intelligence to improve primary care for patients and clinicians. JAMA Intern Med. 2024;184(4):343-344. doi:10.1001/jamainternmed.2023.7965. https://psnet.ahrq.gov/issue/using-a…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74016/psn-pdf
    October 27, 2021 - Malnutrition in Hospitalized Adults: A Systematic Review. October 27, 2021 Uhl S, Siddique SM, McKeever L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2021.  AHRQ Publication No. 21(22)-EHC035. https://psnet.ahrq.gov/issue/malnutrition-hospitalized-adults-systematic-review Patien…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60665/psn-pdf
    July 08, 2020 - Response of practicing chiropractors during the early phase of the COVID-19 pandemic: a descriptive report. July 8, 2020 Johnson CD, Green BN, Konarski-Hart KK, et al. Response of Practicing Chiropractors during the Early Phase of the COVID-19 Pandemic: A Descriptive Report. J Manipulative Physiol Ther. 2020;43(5):…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60631/psn-pdf
    June 24, 2020 - Special report: COVID deepens the other opioid crisis - a shortage of hospital painkillers. June 24, 2020 Girion L, Levine D, Respaut R. Special report: COVID deepens the other opioid crisis - a shortage of hospital painkillers. Reuters. 2020;June 9. https://psnet.ahrq.gov/issue/special-report-covid-deepens-other-…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848383/psn-pdf
    May 03, 2023 - Burnout in Primary Care: Assessing and Addressing It in Your Practice. May 3, 2023 Gerteis J, Booker C, Brach C, et al. Rockville, MD:  Agency for Healthcare Research and Quality; February 2023. AHRQ Publication No. 23-0025. https://psnet.ahrq.gov/issue/burnout-primary-care-assessing-and-addressing-it-your-pr…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865346/psn-pdf
    March 27, 2024 - RaDonda Vaught says some system practices contributed to fatal mistake. March 27, 2024 Clark C. MedPage Today. March 14, 2024. https://psnet.ahrq.gov/issue/vaught-says-some-system-practices-contributed-fatal-mistake Stories from clinicians involved in errors provide unique insights into both the human an…

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