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psnet.ahrq.gov/node/43183/psn-pdf
May 14, 2014 - Physician: 'I almost killed a patient' because of an
advance directive.
May 14, 2014
Betbeze P. HealthLeaders Media. May 2, 2014.
https://psnet.ahrq.gov/issue/physician-i-almost-killed-patient-because-advance-directive
Reporting on how misinterpretation of advance directives and living wills can detract from patie…
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psnet.ahrq.gov/node/39690/psn-pdf
July 21, 2010 - Characteristics of quality and patient safety curricula in
major teaching hospitals.
July 21, 2010
Pingleton SK, Davis DA, Dickler RM. Characteristics of quality and patient safety curricula in major
teaching hospitals. Am J Med Qual. 2010;25(4):305-11. doi:10.1177/1062860610367677.
https://psnet.ahrq.gov/issue/ch…
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psnet.ahrq.gov/node/41676/psn-pdf
September 24, 2016 - Taking a detour: positive and negative effects of
supervisors' interruptions during admission case review
discussions.
September 24, 2016
Goldszmidt M, Aziz N, Lingard LA. Taking a detour: positive and negative effects of supervisors'
interruptions during admission case review discussions. Acad Med. 2012;87(10):13…
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psnet.ahrq.gov/node/39830/psn-pdf
April 17, 2011 - 2010 Annual National Patient Safety Foundation
Congress: conference proceedings.
April 17, 2011
Pinakiewicz DC, Bonacum D, Youngberg BJ, et al. 2010 Annual National Patient Safety Foundation
Congress: conference proceedings. J Patient Saf. 2010;6(3):128-36.
https://psnet.ahrq.gov/issue/2010-annual-national-patient…
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psnet.ahrq.gov/node/38574/psn-pdf
November 21, 2016 - Family-identified barriers to medication reconciliation.
November 21, 2016
Riley-Lawless K. Family-identified barriers to medication reconciliation. J Spec Pediatr Nurs.
2009;14(2):94-101. doi:10.1111/j.1744-6155.2009.00182.x.
https://psnet.ahrq.gov/issue/family-identified-barriers-medication-reconciliation
Medica…
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psnet.ahrq.gov/node/37527/psn-pdf
August 24, 2015 - MEDMARX Data Report: A Report on the Relationship of
Drug Names and Medication Errors in Response to the
Institute of Medicine's Call to Action (2003-2006 Findings
and Trends 2002-2006).
August 24, 2015
Hicks RW, Becker SC, Cousins DD, eds. Rockville, MD: Center for the Advancement of Patient Safety, US
Pharmacop…
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psnet.ahrq.gov/node/34757/psn-pdf
November 18, 2015 - Unity of Mistakes: A Phenomenological Interpretation of
Medical Work.
November 18, 2015
Paget MA. Philadelphia: Temple University Press; 2004.
https://psnet.ahrq.gov/issue/unity-mistakes-phenomenological-interpretation-medical-work
In this often described landmark text on the nature of medical error, Marianne Page…
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psnet.ahrq.gov/node/45006/psn-pdf
April 06, 2016 - Quality and Patient Safety.
April 6, 2016
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/quality-and-patient-safety
The Agency for Healthcare Research and Quality has provided access to patient safety research,
information, and tools for nearly two decades. This website offers a wide rang…
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psnet.ahrq.gov/node/44016/psn-pdf
November 21, 2016 - Partnering to Improve Quality and Safety: A Framework
for Working With Patient and Family Advisors.
November 21, 2016
Chicago, IL: Health Research & Educational Trust; 2015.
https://psnet.ahrq.gov/issue/partnering-improve-quality-and-safety-framework-working-patient-and-family-
advisors
Patient and family advisor…
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psnet.ahrq.gov/node/45995/psn-pdf
May 24, 2017 - Patient Safety.
May 24, 2017
Todd DW, Bennett JD, eds. Oral Maxillofac Surg Clin North Am. 2017;29:121-244.
https://psnet.ahrq.gov/issue/patient-safety-13
Articles in this special issue provide insights into how human error can affect the safety of oral and
maxillofacial surgery, a primarily ambulatory environment…
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psnet.ahrq.gov/node/44091/psn-pdf
January 04, 2019 - Isolation precautions for visitors.
January 4, 2019
Munoz-Price LS, Banach DB, Bearman G, et al. Isolation Precautions for Visitors. Infect Control Hosp
Epidemiol. 2015;36(7):747-758. doi:10.1017/ice.2015.67.
https://psnet.ahrq.gov/issue/isolation-precautions-visitors
This expert guidance provides recommendations …
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psnet.ahrq.gov/node/43376/psn-pdf
January 16, 2017 - Resilience and resilience engineering in health care.
January 16, 2017
Fairbanks RJ, Wears RL, Woods DD, et al. Resilience and resilience engineering in health care. Jt Comm J
Qual Patient Saf. 2014;40(8):376-383.
https://psnet.ahrq.gov/issue/resilience-and-resilience-engineering-health-care
Resilience is a charac…
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psnet.ahrq.gov/node/60587/psn-pdf
June 10, 2020 - Person-Centered Guidelines for Preserving Family
Presence in Challenging Times.
June 10, 2020
Derby, CT: Planetree; 2020.
https://psnet.ahrq.gov/issue/person-centered-guidelines-preserving-family-presence-challenging-times
Families have an important role in keeping patients safe. This book provides a set of patien…
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psnet.ahrq.gov/node/37793/psn-pdf
February 15, 2011 - Educating seniors to be patient safety self-advocates in
primary care.
February 15, 2011
Elder NC, Regan SL, Pallerla H, et al. Educating Seniors to Be Patient Safety Self-Advocates in Primary
Care. J Patient Saf. 2008;4(2). doi:10.1097/pts.0b013e318175d806.
https://psnet.ahrq.gov/issue/educating-seniors-be-patien…
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psnet.ahrq.gov/node/41222/psn-pdf
May 01, 2016 - Reducing Unnecessary Hospital Readmissions: The Role
of the Patient Safety Organization (PSO).
May 1, 2016
Agency for Healthcare Quality and Research.
https://psnet.ahrq.gov/issue/reducing-unnecessary-hospital-readmissions-role-patient-safety-organization-
pso
Patient safety organizations (PSO) present a unique o…
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psnet.ahrq.gov/node/34788/psn-pdf
March 28, 2005 - Cost of medication-related problems at a university
hospital.
March 28, 2005
Schneider PJ; Gift MG; Lee YP; Rothermich EA; Sill BE
https://psnet.ahrq.gov/issue/cost-medication-related-problems-university-hospital
This study used retrospective chart review to determine estimated costs of defined medication-related
…
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psnet.ahrq.gov/node/35193/psn-pdf
July 10, 2008 - Diagnostic error in internal medicine.
July 10, 2008
Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med.
2005;165(13):1493-1499.
https://psnet.ahrq.gov/issue/diagnostic-error-internal-medicine
This study identified 100 cases of diagnostic error in internal medicine and conducte…
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psnet.ahrq.gov/node/34036/psn-pdf
March 28, 2005 - National Center for Patient Safety Falls Toolkit 2004.
March 28, 2005
Department of Veterans Affairs (VA) National Center for Patient Safety
https://psnet.ahrq.gov/issue/national-center-patient-safety-falls-toolkit-2004
The National Center for Patient Safety created the Falls Toolkit to assist VA facilities in impl…
-
psnet.ahrq.gov/node/39486/psn-pdf
May 05, 2010 - Understanding handling of drug safety alerts: a
simulation study.
May 5, 2010
van der Sijs H, van Gelder T, Vulto A, et al. Understanding handling of drug safety alerts: a simulation
study. Int J Med Inform. 2010;79(5). doi:10.1016/j.ijmedinf.2010.01.008.
https://psnet.ahrq.gov/issue/understanding-handling-drug-sa…
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psnet.ahrq.gov/node/41081/psn-pdf
February 01, 2012 - Workarounds in the use of IS in healthcare: a case study
of an electronic medication administration system.
February 1, 2012
Yang Z, Ng B-Y, Kankanhalli A, et al. Workarounds in the use of IS in healthcare: A case study of an
electronic medication administration system. International Journal of Human-Computer Studi…