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7681. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/854642/psn-pdf
      October 18, 2023 - Cybersecurity for the Clinician. October 18, 2023 Chicago, IL: American Medical Association; 2023. https://psnet.ahrq.gov/issue/cybersecurity-clinician The vulnerability of healthcare information technologies and devices to malicious interruptions is increasingly recognized as a patient safety hazard. This eight-e…

7682. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36412/psn-pdf
      December 22, 2010 - Ambiguities of chronic illness management and challenges to the medical error paradigm. December 22, 2010 Lutfey KE, Freese J. Ambiguities of chronic illness management and challenges to the medical error paradigm. Soc Sci Med. 2007;64(2):314-25. https://psnet.ahrq.gov/issue/ambiguities-chronic-illness-management-…

7683. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38184/psn-pdf
      February 16, 2011 - Interprofessional communication and medical error: a reframing of research questions and approaches. February 16, 2011 Varpio L, Hall P, Lingard LA, et al. Interprofessional communication and medical error: a reframing of research questions and approaches. Acad Med. 2008;83(10 Suppl):S76-81. doi:10.1097/ACM.0b013e…

7684. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40947/psn-pdf
      January 29, 2019 - WHO Patient Safety Curriculum Guide: Multi-Professional Edition. January 29, 2019 WHO Patient Safety. Geneva, Switzerland: World Health Organization; October 2011. ISBN: 9789241501958. https://psnet.ahrq.gov/issue/who-patient-safety-curriculum-guide-multi-professional-edition This multi-professional patient safet…

7685. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40230/psn-pdf
      November 23, 2016 - Talking with Patients and Families about Medical Error: A Guide for Education and Practice. November 23, 2016 Truog RD, Browning DM, Johnson JA, Gallagher TH. Baltimore, MD: Johns Hopkins University Press; 2011. ISBN: 0801898048. https://psnet.ahrq.gov/issue/talking-patients-and-families-about-medical-error-guide-…

7686. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34743/psn-pdf
      March 28, 2005 - Juran's Quality Handbook. 5th ed. March 28, 2005 Juran JM; Blanton GA. New York: McGraw Hill; 1999. ISBN: 9780071165396. https://psnet.ahrq.gov/issue/jurans-quality-handbook-5th-ed This reference on quality engineering and management practices provides a wealth of background and scholarship on the elemen…

7687. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34601/psn-pdf
      January 26, 2009 - Strategies and tips for maximizing failure mode and effect analysis in your organization. January 26, 2009 Chicago, IL: American Society of Healthcare Risk Management; 2002. https://psnet.ahrq.gov/issue/strategies-and-tips-maximizing-failure-mode-and-effect-analysis-your- organization The implementation and appli…

7688. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44115/psn-pdf
      June 03, 2015 - An approach to assessing patient safety in hospitals in low-income countries. June 3, 2015 Lindfield R, Knight A, Bwonya D. An approach to assessing patient safety in hospitals in low-income countries. PLoS One. 2015;10(3):e0121628. doi:10.1371/journal.pone.0121628. https://psnet.ahrq.gov/issue/approach-assessing-…

7689. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74246/psn-pdf
      January 12, 2022 - Patient Safety. January 12, 2022 Dean J, Subbe C, eds. Future Healthc J. 2021;8(3):e559-e618. https://psnet.ahrq.gov/issue/patient-safety-23 Full realization of the patient voice as a resource for safety is challenging. This special section provides global perspectives examining cultural, organizational, and syste…

7690. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36810/psn-pdf
      November 19, 2014 - A Systems Approach to Quality Improvement in Long- Term Care: Safe Medication Practices Workbook. November 19, 2014 Massachusetts Coalition for the Prevention of Medical Errors, MassPRO, Massachusetts Extended Care Foundation. Boston, MA: Commonwealth of Massachusetts; 2008. https://psnet.ahrq.gov/issue/systems-ap…

7691. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50812/psn-pdf
      May 03, 2022 - SOPS Nursing Home Survey: What You Need to Know. April 19, 2022 Agency for Healthcare Research and Quality. May 3, 2022. https://psnet.ahrq.gov/issue/sops-nursing-home-survey-what-you-need-know This webcast provided an overview of AHRQ’s patient safety culture survey focused on nursing homes in support of efforts …

7692. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866322/psn-pdf
      July 17, 2024 - UCSF Coordinating Center for Diagnostic Excellence (CoDEx). July 17, 2024 University of California, San Francisco. https://psnet.ahrq.gov/issue/ucsf-coordinating-center-diagnostic-excellence-codex Diagnostic excellence is an emergent field of study that aligns with diagnostic error reduction efforts. This center …

7693. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40712/psn-pdf
      August 24, 2011 - Automatic detection of omissions in medication lists. August 24, 2011 Hasan S, Duncan GT, Neill DB, et al. Automatic detection of omissions in medication lists. J Am Med Inform Assoc. 2011;18(4):449-58. doi:10.1136/amiajnl-2011-000106. https://psnet.ahrq.gov/issue/automatic-detection-omissions-medication-lists Thi…

7694. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44720/psn-pdf
      December 16, 2015 - The persistent problem of diagnostic error. December 16, 2015 Lundberg GD. Medscape. December 1, 2015. https://psnet.ahrq.gov/issue/persistent-problem-diagnostic-error Spotlighting the author's experience with autopsies to provide context regarding diagnostic errors as a patient safety problem, this commentary out…

7695. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34733/psn-pdf
      November 19, 2015 - Out of the Crisis. November 19, 2015 Deming WE. Cambridge, MA: Massachusetts Institute of Technology, Center for Advanced Engineering Study, 1986. ISBN: 9780911379013. https://psnet.ahrq.gov/issue/out-crisis Deming believes that American companies need to transform their method of management to engage and compete…

7696. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47348/psn-pdf
      September 05, 2018 - Hospital-Acquired Condition Reduction Program (HACRP). September 5, 2018 QualityNet. Centers for Medicare and Medicaid Services. https://psnet.ahrq.gov/issue/hospital-acquired-condition-hac-reduction-program Eliminating hospital-acquired harm requires policy, organizational, and individual approaches to motivate …

7697. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45306/psn-pdf
      August 17, 2016 - Indiana Patient Safety Center. August 17, 2016 Indiana Hospital Association; IHA. https://psnet.ahrq.gov/issue/indiana-patient-safety-center Launched in 2006, the Indiana Patient Safety Center (IPSC) is dedicated to promoting safety culture and reliable systems of care in the state. This website provides resources…

7698. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40395/psn-pdf
      May 13, 2021 - Hospital Compare. May 13, 2021 Centers for Medicare & Medicaid Services. https://psnet.ahrq.gov/issue/hospital-compare The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site inclu…

7699. Delay in Initiating Antibiotics Results in Fatal Error | PSNet
      psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
      August 02, 2015 - SPOTLIGHT CASE Delay in Initiating Antibiotics Results in Fatal Error Citation Text: Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation …

7700. Medication Mix-Up: From Bad to Worse | PSNet
      psnet.ahrq.gov/web-mm/medication-mix-bad-worse
      March 01, 2018 - Medication Mix-Up: From Bad to Worse Citation Text: Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote …