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7561. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33587/psn-pdf
      June 15, 2024 - Missed Nursing Care June 15, 2024 Missed Nursing Care. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/missed-nursing-care PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed…

7562. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35318/psn-pdf
      September 20, 2024 - AHRQ Quality Indicators. September 20, 2024 Agency for Healthcare Research and Quality https://psnet.ahrq.gov/issue/ahrq-quality-indicators The Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QIs) represent quality measures that make use of a hospital's available administrative data to inform…

7563. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36172/psn-pdf
      August 09, 2006 - The Patient Safety Group. August 9, 2006 https://psnet.ahrq.gov/issue/patient-safety-group Development of The Patient Safety Group was motivated by the death of a young girl named Josie King. The King family responded to their personal experience from medical errors by making a commitment to improve and advance sa…

7564. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34114/psn-pdf
      September 20, 2023 - Speak Up Initiative. September 20, 2023 Joint Commission. https://psnet.ahrq.gov/issue/speak-initiative The Speak Up campaign provides sets of materials to enable patients and families to engage in making their health care experiences as safe as possible. Topics covered include safe surgery, pain management, medi…

7565. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34972/psn-pdf
      May 11, 2017 - 2017 ISMP Medication Safety Self Assessment® for Antithrombotic Therapy in Hospitals. May 11, 2017 Horsham, PA: Institute for Safe Medication Practices; March 2017. https://psnet.ahrq.gov/issue/2017-ismp-medication-safety-self-assessmentr-antithrombotic-therapy- hospitals This tool provides institutions with the …

7566. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39539/psn-pdf
      January 13, 2013 - We need leaders: the 48th Annual Rovenstine Lecture. January 13, 2013 Pronovost P. We need leaders: The 48th Annual Rovenstine Lecture. Anesthesiology. 2010;112(4):779- 785. doi:10.1097/ALN.0b013e3181d32047. https://psnet.ahrq.gov/issue/we-need-leaders-48th-annual-rovenstine-lecture Dr. Pronovost provides a histor…

7567. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34105/psn-pdf
      December 24, 2008 - Barcode technology: its role in increasing the safety of blood transfusion. December 24, 2008 Turner CL, Casbard AC, Murphy MF. Barcode technology: its role in increasing the safety of blood transfusion. Transfusion (Paris). 2004;43(9). doi:10.1046/j.1537-2995.2003.00428.x. https://psnet.ahrq.gov/issue/barcode-tec…

7568. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42691/psn-pdf
      October 23, 2013 - Patient Safety Investigation report into services at University Hospital Galway (UHG) and as reflected in the care provided to Savita Halappanavar. October 23, 2013 Dublin, Ireland: Health Information and Quality Authority; October 2013. https://psnet.ahrq.gov/issue/patient-safety-investigation-report-services-uni…

7569. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41429/psn-pdf
      October 17, 2012 - Who makes prescribing decisions in hospital inpatients? An observational study. October 17, 2012 Ross S, Hamilton L, Ryan C, et al. Who makes prescribing decisions in hospital inpatients? An observational study. Postgrad Med J. 2012;88(1043):507-10. doi:10.1136/postgradmedj-2011-130602. https://psnet.ahrq.gov/issu…

7570. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46788/psn-pdf
      April 11, 2018 - Preventing newborn falls and drops. April 11, 2018 Quick Safety. March 27, 2018;(40):1-2. https://psnet.ahrq.gov/issue/preventing-newborn-falls-and-drops Falls are a common patient safety concern for adults but are rarely discussed as a threat to newborn safety. This newsletter article provides a definition for a …

7571. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46500/psn-pdf
      June 27, 2018 - Ariadne Labs. June 27, 2018 Brigham & Women's Hospital; Harvard T.H. Chan School of Public Health. https://psnet.ahrq.gov/issue/ariadne-labs Checklists can help catch gaps in communication and process. This website provides resources related to the use of checklists in surgical, obstetric, and other care environme…

7572. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41578/psn-pdf
      October 09, 2013 - Improving Patient Safety in Long-Term Care Facilities: Training Modules. October 9, 2013 Taylor SL, Saliba D. Rockville, MD: Agency for Healthcare Research and Quality; July 2012. AHRQ Publication No. 12-0001. https://psnet.ahrq.gov/issue/improving-patient-safety-long-term-care-facilities-training-modules This se…

7573. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46003/psn-pdf
      May 10, 2017 - National Healthcare Safety Network. May 10, 2017 Centers for Disease Control and Prevention. https://psnet.ahrq.gov/issue/national-healthcare-safety-network-0 Health care–associated infection are a persistent patient safety problem. This website provides resources related to a national health care–associated infec…

7574. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37580/psn-pdf
      March 05, 2008 - Patient safety events reported in general practice: a taxonomy. March 5, 2008 Makeham MAB, Stromer S, Bridges-Webb C, et al. Patient safety events reported in general practice: a taxonomy. Qual Saf Health Care. 2008;17(1):53-7. doi:10.1136/qshc.2007.022491. https://psnet.ahrq.gov/issue/patient-safety-events-report…

7575. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35034/psn-pdf
      November 05, 2015 - Seven Leadership Leverage Points for Organization-Level Improvement in Health Care. Second edition. November 5, 2015 Reinertsen JL, Bisognano M, Pugh MD. Cambridge, MA: Institute for Healthcare Improvement; 2008. https://psnet.ahrq.gov/issue/seven-leadership-leverage-points-organization-level-improvement-health-car…

7576. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37559/psn-pdf
      March 31, 2025 - John M. Eisenberg Patient Safety and Quality Award. February 4, 2025 Joint Commission, National Quality Forum. https://psnet.ahrq.gov/issue/john-m-eisenberg-patient-safety-and-quality-award The Eisenberg Award honors individuals and organizations who have made key contributions to patient safety and quality improv…

7577. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/856639/psn-pdf
      November 29, 2023 - Impact Wellbeing. November 29, 2023 National Institute for Occupational Safety and Health. Centers for Disease Control and Prevention. https://psnet.ahrq.gov/issue/impact-wellbeing Clinician burnout has become a major concern for both healthcare workforce and patient safety. This portal provides access to too…

7578. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39052/psn-pdf
      July 13, 2010 - Improving handoffs in the emergency department. July 13, 2010 Cheung DS, Kelly JJ, Beach C, et al. Improving handoffs in the emergency department. Ann Emerg Med. 2010;55(2):171-80. doi:10.1016/j.annemergmed.2009.07.016. https://psnet.ahrq.gov/issue/improving-handoffs-emergency-department Reviewing the conceptual f…

7579. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38796/psn-pdf
      April 04, 2011 - A 62-year-old woman with skin cancer who experienced wrong-site surgery. April 4, 2011 Gallagher TH. A 62-year-old woman with skin cancer who experienced wrong-site surgery: review of medical error. JAMA. 2009;302(6):669-77. doi:10.1001/jama.2009.1011. https://psnet.ahrq.gov/issue/62-year-old-woman-skin-cancer-who…

7580. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45735/psn-pdf
      July 17, 2017 - CMPA Good Practices Guide. July 17, 2017 Ottawa, Ontario: Canadian Medical Protective Association; 2016. https://psnet.ahrq.gov/issue/cmpa-good-practices-guide Key patient safety topics include human factors, teamwork, adverse events, communication, professionalism, and risk management. This website provides resou…