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8001. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35564/psn-pdf
      June 17, 2014 - Medication safety issue brief. Small and rural hospitals—unique challenges, unique solutions. June 17, 2014 Association AH, Pharmacists AS of H-S, Networks H & H. Medication Safety Issue Brief. Small and rural hospitals--unique challenges, unique solutions. Hospitals & health networks. 2005;79(11):45-6. https://ps…

8002. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43509/psn-pdf
      September 10, 2014 - Patient Safety in Private Hospitals: the Known and the Unknown Risk. September 10, 2014 Leys C, Toft B. London, UK: Centre for Health and the Public Interest; August 2014. https://psnet.ahrq.gov/issue/patient-safety-private-hospitals-known-and-unknown-risk This report discusses issues with staffing, equipment, and…

8003. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73479/psn-pdf
      July 07, 2021 - Mitigating the July effect. July 7, 2021 Wu AW, Vincent CA, Shapiro DW, et al. Mitigating the July effect. J Patient Saf Risk Manag. 2021;26(3):93-96. doi:10.1177/25160435211019142. https://psnet.ahrq.gov/issue/mitigating-july-effect The July effect is a phenomenon that presumably results in poor care due to the a…

8004. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35477/psn-pdf
      November 16, 2005 - A Safer Place for Patients: Learning to Improve Patient Safety. November 16, 2005 National Audit Office. London UK: The Stationery Office; 2005. ISBN 0102933448. https://psnet.ahrq.gov/issue/safer-place-patients-learning-improve-patient-safety This report details the current state of patient safety in the National…

8005. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44977/psn-pdf
      March 01, 2020 - Choosing a Patient Safety Organization March 1, 2020 Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0030. https://psnet.ahrq.gov/issue/choosing-patient-safety-organization Patient safety organizations (PSOs) collect and analyze protected incident data from across the …

8006. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/845654/psn-pdf
      March 08, 2023 - NHS staff cried in safety interviews, says watchdog. March 8, 2023 Reed J. BBC. February 27, 2023. https://psnet.ahrq.gov/issue/nhs-staff-cried-safety-interviews-says-watchdog Stressful and caustic work environments are known to compromise health care safety and teamwork. This news story discusses an ongoing inves…

8007. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45211/psn-pdf
      October 11, 2016 - Safety in Medication Use. October 11, 2016 Tully MP, Franklin BD, eds. Boca Raton, FL: CRC Press, Taylor and Francis Group; 2016. ISBN: 9781482227000. https://psnet.ahrq.gov/issue/safety-medication-use Errors in the prescription, preparation, and administration of medications hinder safe patient care. This book s…

8008. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44623/psn-pdf
      November 11, 2015 - Quality, Safety, and Noninterpretive Skills. November 11, 2015 Kruskal JB, Kung JW, eds. Radiographics. 2015;35(6):1627-1848. https://psnet.ahrq.gov/issue/quality-safety-and-noninterpretive-skills Increased radiation exposure has emerged as a patient safety problem, with the potential to result in harm for provide…

8009. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44068/psn-pdf
      April 15, 2015 - Contemporary View of Medication-Related Harm. A New Paradigm. April 15, 2015 National Coordinating Council for Medication Error Reporting and Prevention; NCCMERP. https://psnet.ahrq.gov/issue/contemporary-view-medication-related-harm-new-paradigm Medication errors are a common factor in health care–associated harm…

8010. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39865/psn-pdf
      May 28, 2014 - Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction, Third Edition. May 28, 2014 Oakbrook Terrace, IL: Joint Commission Resources; 2010. ISBN: 9781599404066. https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-health-care-proactive-risk-reduction-third- edition This publication p…

8011. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41470/psn-pdf
      November 15, 2024 - Hospital Safety Grade. November 15, 2024 Leapfrog Group https://psnet.ahrq.gov/issue/hospital-safety-grade Drawing from data reported by the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medic…

8012. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42861/psn-pdf
      January 15, 2014 - Transitioning Newborns From NICU to Home: A Resource Toolkit. January 15, 2014 Rockville, MD: Agency for Healthcare Research and Quality; December 2013. AHRQ Publication No. 12(14)-0054-EF. https://psnet.ahrq.gov/issue/transitioning-newborns-nicu-home-resource-toolkit Infants discharged from the neonatal intensiv…

8013. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35859/psn-pdf
      July 22, 2010 - A multifaceted approach to improve patient safety, prevent medical errors and resolve the professional liability crisis. July 22, 2010 Weinstein L. A multifacited approach to improve patient safety, prevent medical errors and resolve the professional liability crisis. Am J Obstet Gynecol. 2006;194(4):1160-5; discu…

8014. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35397/psn-pdf
      September 10, 2009 - The National Medical Error Disclosure and Compensation (MEDiC) Act. September 10, 2009 Rodham-Clinton H; Obama B. 109th Congress. 1st Session. S. 1784. September 28, 2005. https://psnet.ahrq.gov/issue/national-medical-error-disclosure-and-compensation-medic-act This bill, introduced to the Senate by Senators Clint…

8015. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37710/psn-pdf
      April 23, 2008 - A 3-year study of medication incidents in an acute general hospital. April 23, 2008 Song L, Chui WCM, Lau CP, et al. A 3-year study of medication incidents in an acute general hospital. J Clin Pharm Ther. 2008;33(2):109-14. doi:10.1111/j.1365-2710.2007.00880.x. https://psnet.ahrq.gov/issue/3-year-study-medication-…

8016. Patient and Family Roles in Safety | PSNet
      psnet.ahrq.gov/perspective/patient-and-family-roles-safety
      June 14, 2023 - Patient and Family Roles in Safety Beverley H. Johnson, FAAN, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD | June 14, 2023  Also Read the Conversation View more articles from the same authors. Citation Text: Johnson B, Lee M, Mossburg S. Patient and Fam…

8017. In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm | PSNet
      psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
      June 14, 2023 - In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm Beverley H. Johnson, FAAN | June 14, 2023  Also Read the Essay View more articles from the same authors. Citation Text: Johnson B. In Conversation with.. Beverley H…

8018. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38269/psn-pdf
      October 01, 2024 - Nursing Home Survey on Patient Safety Culture. October 1, 2024 Rockville, MD: Agency for Healthcare Research and Quality; October 2020. https://psnet.ahrq.gov/issue/nursing-home-survey-patient-safety-culture Challenges to establishing and sustaining a safety culture in a nursing home include insufficient staffing …

8019. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34117/psn-pdf
      December 23, 2016 - Sentinel Event. December 23, 2016 The Joint Commission. https://psnet.ahrq.gov/issue/sentinel-event Since 1998, The Joint Commission has issued sentinel event alerts in response to unexpected incidents involving death or serious physical or psychological injury (or risk thereof). These events are identified as se…

8020. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/854639/psn-pdf
      October 18, 2023 - Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive. October 18, 2023 Edmondson A. Atria Books, New York, 2023. ISBN: 9781982195069. https://psnet.ahrq.gov/issue/right-kind-wrong-why-learning-fail-can-teach-us-thrive Despite the harm that failure can cause, its value as a learning opportunity, if exam…