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6961. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41581/psn-pdf
      August 08, 2012 - How-to Guides: Improving Transitions from the Hospital to Reduce Avoidable Rehospitalizations. August 8, 2012 Cambridge, MA: Institute for Healthcare Improvement; June 2012. https://psnet.ahrq.gov/issue/how-guides-improving-transitions-hospital-reduce-avoidable-rehospitalizations This series, developed in conjunct…

6962. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35591/psn-pdf
      December 21, 2005 - WHO Draft Guidelines for Adverse Event Reporting and Learning Systems. December 21, 2005 World Alliance for Patient Safety. Geneva, Switzerland: World Health Organization; 2005. https://psnet.ahrq.gov/issue/who-draft-guidelines-adverse-event-reporting-and-learning-systems These guidelines present background on the…

6963. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39153/psn-pdf
      December 02, 2009 - Checking the right boxes, but failing the patient. December 2, 2009 Rifkin D. New York Times. November 16, 2009;Science Desk:5. https://psnet.ahrq.gov/issue/checking-right-boxes-failing-patient Reporting on cases of miscommunication and missed diagnosis, this news column illustrates how strictly following quality …

6964. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36741/psn-pdf
      August 15, 2007 - Prescription for Improving Patient Safety: Addressing Medication Errors. August 15, 2007 The Medication Errors Panel. Sacramento, CA: California State Senate; March 2007.   https://psnet.ahrq.gov/issue/prescription-improving-patient-safety-addressing-medication-errors This report shares findings from an exper…

6965. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37027/psn-pdf
      September 12, 2007 - Why King-Harbor must die. September 12, 2007 Wachter RM. https://psnet.ahrq.gov/issue/why-king-harbor-must-die Recently, California health officials have argued to revoke the license of King-Harbor Hospital, owing to concerns about patient safety. In this op-ed piece, the author suggests that this urban hospital i…

6966. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41202/psn-pdf
      March 07, 2012 - Reducing latent errors, drift errors, and stakeholder dissonance. March 7, 2012 Samaras GM. Work: J Prev Assess Rehabil. 2012;41:1948-1955. https://psnet.ahrq.gov/issue/reducing-latent-errors-drift-errors-and-stakeholder-dissonance This commentary discusses system and user errors in health information technology a…

6967. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36514/psn-pdf
      May 11, 2014 - Medication reconciliation physician order form. May 11, 2014 Lacy JL, Wilkinson ST. Medication Reconciliation Physician Order Form. Hosp Pharm. 2010;41(11):1117- 1119. doi:10.1310/hpj4111-1117. https://psnet.ahrq.gov/issue/medication-reconciliation-physician-order-form The authors discuss background on one hospita…

6968. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34620/psn-pdf
      March 17, 2011 - Consumers Advancing Patient Safety. March 17, 2011 321 N Clark Street, Suite 500, Chicago, IL 60654. 312-445-6477 https://psnet.ahrq.gov/issue/consumers-advancing-patient-safety Consumers Advancing Patient Safety (CAPS) is a consumer-led nonprofit organization that serves as a collective voice for individuals, fam…

6969. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37506/psn-pdf
      March 12, 2019 - FDA public health notification: unretrieved device fragments. March 12, 2019 Silver Spring MD, Center for Devices and Radiological Health, US Food and Drug Administration; January 15, 2008. https://psnet.ahrq.gov/issue/fda-public-health-notification-unretrieved-device-fragments This notification alerts providers …

6970. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38653/psn-pdf
      May 20, 2009 - The frustrating case of incident-reporting systems. May 20, 2009 Shojania KG. The frustrating case of incident-reporting systems. Qual Saf Health Care. 2008;17(6):400-2. doi:10.1136/qshc.2008.029496. https://psnet.ahrq.gov/issue/frustrating-case-incident-reporting-systems This commentary discusses the limitations …

6971. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41059/psn-pdf
      May 28, 2014 - The Nurse's Role in Medication Safety, Second Edition. May 28, 2014 Cima L, Clarke S, eds. Oakbrook Terrace, IL: Joint Commission; 2012. ISBN: 9781599406183 https://psnet.ahrq.gov/issue/nurses-role-medication-safety-second-edition Exploring nurses' role in care delivery and medication safety, this publication provi…

6972. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36959/psn-pdf
      September 12, 2011 - Health care governance for quality and safety: the new agenda. September 12, 2011 Clough J, Nash DB. Health care governance for quality and safety: the new agenda. Am J Med Qual. 2007;22(3):203-13. https://psnet.ahrq.gov/issue/health-care-governance-quality-and-safety-new-agenda The authors provide an annotated l…

6973. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35071/psn-pdf
      November 04, 2015 - Implementation, CPOE, and medication errors.   November 4, 2015 Bradley V. Implementation, CPOE, and medication errors. Comput Inform Nurs. 2005;23(3):113-114, 138. https://psnet.ahrq.gov/issue/implementation-cpoe-and-medication-errors In this editorial, a nurse informaticist responds to issues raised by the March …

6974. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33948/psn-pdf
      December 18, 2008 - Patient safety laboratories: states pave the way for a national effort. December 18, 2008 Finkelstein JB. American Medical News. January 3, 2005. https://psnet.ahrq.gov/issue/patient-safety-laboratories-states-pave-way-national-effort States can find themselves in a position to make progress on patient safety…

6975. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40723/psn-pdf
      August 24, 2011 - ALERT: reports of severe harm after intravenous administration of breast milk to infants. August 24, 2011 ISMP Canada Safety Bulletin. July 31, 2011;11:1-2.   https://psnet.ahrq.gov/issue/alert-reports-severe-harm-after-intravenous-administration-breast-milk-infants This announcement reports on mistaken intra…

6976. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36729/psn-pdf
      June 17, 2014 - Coding for Success: Simple Technology for Safer Patient Care. June 17, 2014 Healthcare Quality Directorate, Department of Health. London, UK; Crown Copyright: 2007. https://psnet.ahrq.gov/issue/coding-success-simple-technology-safer-patient-care This report discusses the impact that automated technologies, such as…

6977. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34122/psn-pdf
      September 13, 2016 - Patient Safety, Risk and Quality. September 13, 2016 ECRI https://psnet.ahrq.gov/issue/patient-safety-risk-and-quality ECRI is a nonprofit health services research agency. Their mission involves improving the safety, quality, and cost-effectiveness of health care. ECRI focuses on health care technology, health car…

6978. Event Listings | PSNet
      psnet.ahrq.gov/training-catalog/event-listings
      September 01, 2025 - Event Listings Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Organization: Organization Betsy Lehman Center for Patient Safety Event Description: This page promotes p…

6979. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33955/psn-pdf
      June 23, 2015 - Organisational Failure: An Exploratory Study in the Steel Industry and Medical Domain. June 23, 2015 van Vuuren W. Eindhoven, NL; Eindhoven University of Technology: 1998. ISBN 9038605897 https://psnet.ahrq.gov/issue/organisational-failure-exploratory-study-steel-industry-and-medical-domain This report provides a …

6980. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35142/psn-pdf
      September 22, 2014 - Medical Errors and Medical Narcissism. September 22, 2014 Banja JD. Sudbury MA: Jones and Bartlett, 2005. ISBN: 0763783617. https://psnet.ahrq.gov/issue/medical-errors-and-medical-narcissism This book chronicles the issues surrounding appropriate disclosure of medical errors by health care professionals. The …