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7421. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33972/psn-pdf
      June 14, 2011 - Maximize Patient Safety with Advanced Root Cause Analysis. June 14, 2011 Corbett C, Clapper C, Johnson KM, et al. Middleton, MA: HCPro; 2004. ISBN: 1578393485 https://psnet.ahrq.gov/issue/maximize-patient-safety-advanced-root-cause-analysis A "how-to" book for organizations that have already implemented a root cau…

7422. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35712/psn-pdf
      August 27, 2010 - ACOG Committee Opinion #464: patient safety in the surgical environment. August 27, 2010 Committee Opinion No. 464: Patient Safety in the Surgical Environment. Obstetrics & Gynecology. 2010;116(3). doi:10.1097/aog.0b013e3181f69b22. https://psnet.ahrq.gov/issue/acog-committee-opinion-464-patient-safety-surgical-env…

7423. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41881/psn-pdf
      November 28, 2012 - Prevention of fatal opioid overdose. November 28, 2012 Beletsky L, Rich JD, Walley AY. Prevention of fatal opioid overdose. JAMA. 2012;308(18):1863-4. doi:10.1001/jama.2012.14205. https://psnet.ahrq.gov/issue/prevention-fatal-opioid-overdose This commentary recommends that health care providers and government agen…

7424. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41918/psn-pdf
      December 19, 2012 - 5 most commonly misdiagnosed conditions in the ICU. December 19, 2012 Agnvall E. AARP. November 16, 2012. https://psnet.ahrq.gov/issue/5-most-commonly-misdiagnosed-conditions-icu This article discusses five conditions often associated with diagnostic errors in intensive care units and provides tips for patients an…

7425. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36278/psn-pdf
      February 15, 2010 - Quality improvement to decrease specimen mislabeling in transfusion medicine. February 15, 2010 Quillen K, Murphy K. Quality improvement to decrease specimen mislabeling in transfusion medicine. Arch Pathol Lab Med. 2006;130(8):1196-1198. https://psnet.ahrq.gov/issue/quality-improvement-decrease-specimen-mislabeli…

7426. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42573/psn-pdf
      September 04, 2013 - QI Gateway: Quality Improvement for Residents. September 4, 2013 The Committee of Interns and Residents; CIR; SEIU Healthcare. https://psnet.ahrq.gov/issue/qi-gateway-quality-improvement-residents This Web site hosts resources for resident physicians to support collaboration on safety and quality activities at tea…

7427. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43204/psn-pdf
      May 21, 2014 - Be an Active Member of Your Health Care Team. May 21, 2014 US Food and Drug Administration; FDA. https://psnet.ahrq.gov/issue/be-active-member-your-health-care-team This fact sheet describes five ways patients can contribute to and ensure safe medication use, including speaking up about medical history, asking que…

7428. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42592/psn-pdf
      May 20, 2015 - Healthcare–Associated Infections (HAI). May 20, 2015 Centers for Disease Control and Prevention; CDC. https://psnet.ahrq.gov/issue/healthcare-associated-infections-hai This Web site provides information about government initiatives to research and prevent health care–associated infections. https://psnet.ahrq.gov/…

7429. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37509/psn-pdf
      January 30, 2008 - Hidden danger, obvious opportunity: error and risk in the management of cancer. January 30, 2008 Munro AJ. Hidden danger, obvious opportunity: error and risk in the management of cancer. Br J Radiol. 2007;80(960):955-66. https://psnet.ahrq.gov/issue/hidden-danger-obvious-opportunity-error-and-risk-management-cance…

7430. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36293/psn-pdf
      July 14, 2010 - Hospital internet site content on patient safety and medical errors. July 14, 2010 Heffner JE, Webster L, Ellis R. J Patient Saf. 2006;2(2):72-77. https://psnet.ahrq.gov/issue/hospital-internet-site-content-patient-safety-and-medical-errors The authors looked at safety program–related content on 250 US hospitals' …

7431. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38834/psn-pdf
      January 03, 2017 - What are the critical success factors for team training in health care? January 3, 2017 Salas E, Almeida SA, Salisbury M, et al. What are the critical success factors for team training in health care? Jt Comm J Qual Patient Saf. 2009;35(8):398-405. https://psnet.ahrq.gov/issue/what-are-critical-success-factors-tea…

7432. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39536/psn-pdf
      September 24, 2016 - Losing the moment: understanding interruptions to nurses' work. September 24, 2016 Hall LMG, Pedersen C, Fairley L. Losing the moment: understanding interruptions to nurses' work. J Nurs Adm. 2010;40(4):169-176. doi:10.1097/NNA.0b013e3181d41162. https://psnet.ahrq.gov/issue/losing-moment-understanding-interruption…

7433. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37953/psn-pdf
      July 30, 2008 - The increased incidence of anesthetic adverse events in late afternoon surgeries. July 30, 2008 Johnson J. The increased incidence of anesthetic adverse events in late afternoon surgeries. AORN J. 2008;88(1):79-87. doi:10.1016/j.aorn.2008.02.020. https://psnet.ahrq.gov/issue/increased-incidence-anesthetic-adverse-…

7434. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36533/psn-pdf
      May 27, 2011 - Effect of computerisation on the quality and safety of chemotherapy prescription. May 27, 2011 Voeffray M, Pannatier A, Stupp R, et al. Effect of computerisation on the quality and safety of chemotherapy prescription. Qual Saf Health Care. 2006;15(6):418-21. https://psnet.ahrq.gov/issue/effect-computerisation-qual…

7435. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41259/psn-pdf
      June 27, 2022 - Making health care safer: stopping C. difficile infections. June 27, 2022 Centers for Disease Control and Prevention. https://psnet.ahrq.gov/issue/making-health-care-safer-stopping-c-difficile-infections This newsletter article and accompanying set of infographics describes strategies to help patients and health c…

7436. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37864/psn-pdf
      August 06, 2016 - Improving Healthcare Team Communication: Building on Lessons from Aviation and Aerospace. August 6, 2016 Nemeth CP, ed. Burlington, VT: Ashgate Publishing; 2008. ISBN: 9780754670254. https://psnet.ahrq.gov/issue/improving-healthcare-team-communication-building-lessons-aviation-and- aerospace This book provides an…

7437. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38321/psn-pdf
      June 17, 2014 - No bad apples. June 17, 2014 Thrall TH. No bad apples. Hospitals & health networks. 2008;82(12):42-4, 1. https://psnet.ahrq.gov/issue/no-bad-apples This article provides context on a recent study and Joint Commission alert regarding how disruptive behavior may affect patient safety and describes steps hospitals ca…

7438. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37905/psn-pdf
      December 19, 2018 - Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. December 19, 2018 Nance JJ. Boseman, MT: Second River Healthcare Press; 2008. ISBN: 9780974386058. https://psnet.ahrq.gov/issue/why-hospitals-should-fly-ultimate-flight-plan-patient-safety-and-quality-care This book describes si…

7439. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39310/psn-pdf
      April 01, 2010 - Some unintended effects of teamwork in healthcare. April 1, 2010 Finn R, Learmonth M, Reedy P. Some unintended effects of teamwork in healthcare. Soc Sci Med. 2010;70(8):1148-54. doi:10.1016/j.socscimed.2009.12.025. https://psnet.ahrq.gov/issue/some-unintended-effects-teamwork-healthcare This study explores the di…

7440. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37192/psn-pdf
      November 26, 2008 - Reducing the Risk by Designing a Safer, Shame-free Health Care Environment. November 26, 2008 Abrams MA, Hung LL, Kashuba AB, et al. Chicago, IL: American Medical Association; 2007. https://psnet.ahrq.gov/issue/reducing-risk-designing-safer-shame-free-health-care-environment This monograph provides background on h…