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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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 …
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. Psn-Pdf (pdf file)

    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 …
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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…

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