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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43875/psn-pdf
    September 19, 2016 - Implementation of a "second victim" program in a pediatric hospital. September 19, 2016 Krzan KD, Merandi J, Morvay S, et al. Implementation of a "second victim" program in a pediatric hospital. Am J Health Syst Pharm. 2015;72(7):563-7. doi:10.2146/ajhp140650. https://psnet.ahrq.gov/issue/implementation-second-vic…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42825/psn-pdf
    December 18, 2013 - Primary care physician communication at hospital discharge reduces medication discrepancies. December 18, 2013 Lindquist LA, Yamahiro A, Garrett A, et al. Primary care physician communication at hospital discharge reduces medication discrepancies. J Hosp Med. 2013;8(12):672-7. doi:10.1002/jhm.2098. https://psnet.a…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40992/psn-pdf
    December 15, 2011 - Should patients get direct access to their laboratory test results?: An answer with many questions. December 15, 2011 Giardina TD, Singh H. Should patients get direct access to their laboratory test results? An answer with many questions. JAMA. 2011;306(22):2502-2503. doi:10.1001/jama.2011.1797. https://psnet.ahrq…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46750/psn-pdf
    January 31, 2018 - Iowans' Views on Medical Errors: Iowa Patient Safety Study. January 31, 2018 Clive, IA: Heartland Health Research Institute; January 7, 2018. https://psnet.ahrq.gov/issue/iowans-views-medical-errors-iowa-patient-safety-study Patient perspectives can provide insights regarding areas in need of improvement. This sur…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60346/psn-pdf
    May 20, 2020 - The need to include assisted living in responding to the COVID-19 pandemic. May 20, 2020 Zimmerman S, Sloane PD, Katz PR, et al. The need to include assisted living in responding to the COVID- 19 pandemic. J Am Med Dir Assoc. 2020;21(5). doi:10.1016/j.jamda.2020.03.024. https://psnet.ahrq.gov/issue/need-include-as…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41173/psn-pdf
    February 29, 2012 - Root causes of errors in a simulated prehospital pediatric emergency. February 29, 2012 Lammers RL, Byrwa M, Fales W. Root causes of errors in a simulated prehospital pediatric emergency. Acad Emerg Med. 2012;19(1):37-47. doi:10.1111/j.1553-2712.2011.01252.x. https://psnet.ahrq.gov/issue/root-causes-errors-simulat…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837209/psn-pdf
    May 25, 2022 - Opioids and falls risk in older adults: a narrative review. May 25, 2022 Virnes R-E, Tiihonen M, Karttunen N, et al. Opioids and falls risk in older adults: a narrative review. Drugs Aging. 2022;39(3):199-207. doi:10.1007/s40266-022-00929-y. https://psnet.ahrq.gov/issue/opioids-and-falls-risk-older-adults-narrative…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867395/psn-pdf
    December 18, 2024 - AHRQ National Healthcare Safety Dashboard. December 18, 2024 AHRQ National Healthcare Safety Dashboard. National Action Alliance for Patient and Workforce Safety. https://psnet.ahrq.gov/issue/ahrq-national-healthcare-safety-dashboard The AHRQ National Healthcare Safety Dashboard is one approach to tracking progress…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43753/psn-pdf
    December 10, 2014 - Improving the quality and safety of patient care in cardiac anesthesia. December 10, 2014 Merry A, Weller J, Mitchell SJ. Improving the quality and safety of patient care in cardiac anesthesia. J Cardiothorac Vasc Anesth. 2014;28(5):1341-51. doi:10.1053/j.jvca.2014.02.018. https://psnet.ahrq.gov/issue/improving-qu…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865493/psn-pdf
    April 03, 2024 - Implement strategies to prevent persistent medication errors and hazards: 2024. April 3, 2024 ISMP Medication Safety Alert! Acute Care. 2024;29(6):1-4. https://psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards-2024 Systemic failures can perpetuate unsafe care if a lack of p…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38200/psn-pdf
    November 05, 2008 - Measuring mobile patient safety information system success: an empirical study. November 5, 2008 Jen W-Y, Chao C-C. Measuring mobile patient safety information system success: an empirical study. Int J Med Inform. 2008;77(10):689-97. doi:10.1016/j.ijmedinf.2008.03.003. https://psnet.ahrq.gov/issue/measuring-mobile…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50594/psn-pdf
    October 30, 2019 - Pharmacist linkage in care transitions: from academic medical center to community. October 30, 2019 Bloodworth LS, Malinowski SS, Lirette ST, et al. Pharmacist linkage in care transitions: from academic medical center to community. J Am Pharm Assoc . 2019;59(6):896-904. doi:10.1016/j.japh.2019.08.011. https://psne…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43018/psn-pdf
    March 19, 2014 - Improved obstetric safety through programmatic collaboration. March 19, 2014 Goffman D, Brodman M, Friedman AJ, et al. Improved obstetric safety through programmatic collaboration. J Healthc Risk Manag. 2014;33(3):14-22. doi:10.1002/jhrm.21131. https://psnet.ahrq.gov/issue/improved-obstetric-safety-through-program…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44192/psn-pdf
    November 10, 2015 - Hospital ratings: a guide for the perplexed. November 10, 2015 Zuger A. Hospital ratings: a guide for the perplexed. JAMA. 2015;313(19):1911-2. doi:10.1001/jama.2015.5269. https://psnet.ahrq.gov/issue/hospital-ratings-guide-perplexed Concerns have been raised about the variability of measures used to rate safety a…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45163/psn-pdf
    November 30, 2016 - The 2015 John M. Eisenberg Patient Safety and Quality Awards. November 30, 2016 Jt Comm J Qual Patient Saf. 2016;42(6):243-264. https://psnet.ahrq.gov/issue/2015-john-m-eisenberg-patient-safety-and-quality-awards The Eisenberg Award honors individuals and organizations who have made vital accomplishments in impro…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39110/psn-pdf
    June 10, 2018 - Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. November 5, 2009;14:1-3. https://psnet.ahrq.gov/issue/order-scanning-systems-may-pull-multiple-pages-through-scanner-same-time- leading-dru…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47647/psn-pdf
    January 23, 2019 - Patient Safety: Global Action on Patient Safety. January 23, 2019 Executive Board EB144/29 144th session. Geneva, Switzerland: World Health Organization; December 12, 2018. https://psnet.ahrq.gov/issue/patient-safety-global-action-patient-safety This guidance summarizes the current status of global patient safety,…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35704/psn-pdf
    March 28, 2011 - Relationship between patient complaints and surgical complications. March 28, 2011 Murff HJ, France DJ, Blackford J, et al. Relationship between patient complaints and surgical complications. Qual Saf Health Care. 2006;15(1):13-6. https://psnet.ahrq.gov/issue/relationship-between-patient-complaints-and-surgical-co…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37276/psn-pdf
    December 23, 2011 - Team management training using crisis resource management results in perceived benefits by healthcare workers. December 23, 2011 Rudy SJ, Polomano R, Murray WB, et al. Team management training using crisis resource management results in perceived benefits by healthcare workers. J Contin Educ Nurs. 2007;38(5):219-2…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866257/psn-pdf
    July 25, 2024 - Enhancing Surgical Team Communication: SOPS and TeamSTEPPS in Action. July 10, 2024 Agency for Healthcare Research and Quality. July 25, 2024. https://psnet.ahrq.gov/issue/enhancing-surgical-team-communication-sops-and-teamstepps-action Teamwork in the surgical suite is core to safe care but can be challenging to …

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