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8161. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/847735/psn-pdf
      May 30, 2023 - SOPS Ambulatory Surgery Center Survey: What You Need to Know. May 30, 2023 Agency for Healthcare Policy and Research: April 27, 2023. https://psnet.ahrq.gov/issue/sops-ambulatory-surgery-center-survey-what-you-need-know Ambulatory surgery centers (ASC) experience a variety of error types that can be exacerbated by…

8162. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837600/psn-pdf
      June 29, 2022 - Handoffs and teamwork: a framework for care transition communication. June 29, 2022 Webster KLW, Keebler JR, Lazzara EH, et al. Handoffs and teamwork: a framework for care transition communication. Jt Comm Qual Patient Saf. 2022;48(6-7):343-353. doi:10.1016/j.jcjq.2022.04.001. https://psnet.ahrq.gov/issue/handoffs…

8163. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48049/psn-pdf
      May 29, 2019 - How one health system overcame resistance to a surgical checklist. May 29, 2019 Hilton K, Anderson A. Harv Bus Rev. May 20, 2019. https://psnet.ahrq.gov/issue/how-one-health-system-overcame-resistance-surgical-checklist This commentary describes how one health system worked to combat resistance to change associate…

8164. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50758/psn-pdf
      December 18, 2019 - Still Not Safe: Patient Safety and the Middle-Managing of American Medicine. December 18, 2019 Wears R, Sutcliffe K. New York, NY: Oxford University Press; 2019. ISBN: 9780190271268. https://psnet.ahrq.gov/issue/still-not-safe-patient-safety-and-middle-managing-american-medicine The modern patient safety movement …

8165. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41008/psn-pdf
      December 27, 2014 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. December 27, 2014 Gleason KM, Brake H, Agramonte V, Perfetti C. Rockville, MD: Agency for Healthcare Research and Quality; 2012. AHRQ Publication No.11(12)-0059. https://psnet.ahrq.gov/issue/medications-transitions-and-…

8166. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43252/psn-pdf
      August 24, 2016 - Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer. August 24, 2016 Zipperer L, ed. London, UK: Gower Publishing; 2014. ISBN: 9781409438571. https://psnet.ahrq.gov/issue/patient-safety-perspectives-evidence-information-and-knowledge-transfer This book provides information about utilizing …

8167. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41401/psn-pdf
      January 09, 2018 - Understanding Patient Safety, Third Edition. January 9, 2018 Wachter RM, Gupta K. New York, NY: McGraw-Hill Professional; 2017. ISBN: 9781259860249. https://psnet.ahrq.gov/issue/understanding-patient-safety-third-edition The third edition of this widely read textbook, written by national leaders in patient safety, …

8168. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34951/psn-pdf
      February 28, 2011 - Ambiguity and workarounds as contributors to medical error. February 28, 2011 Spear SJ, Schmidhofer M. Ambiguity and workarounds as contributors to medical error. Ann Intern Med. 2005;142(8):627-630. https://psnet.ahrq.gov/issue/ambiguity-and-workarounds-contributors-medical-error This commentary discusses the ro…

8169. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43334/psn-pdf
      July 16, 2014 - Changing our culture: adopting the military aviation safety system. July 16, 2014 Kerber CW. Changing our culture: adopting the military aviation safety system. J Neurointerv Surg. 2014;6(5):332-41. doi:10.1136/neurintsurg-2013-011070. https://psnet.ahrq.gov/issue/changing-our-culture-adopting-military-aviation-sa…

8170. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840168/psn-pdf
      January 01, 2023 - The debrief imperative: building teaming competencies and team effectiveness. November 16, 2022 Tannenbaum SI, Greilich PE. The debrief imperative: building teaming competencies and team effectiveness. BMJ Qual Saf. 2023;32(3):125-128. doi:10.1136/bmjqs-2022-015259. https://psnet.ahrq.gov/issue/debrief-imperative-…

8171. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34725/psn-pdf
      April 07, 2011 - Patient safety: what about the patient? April 7, 2011 Vincent C, Coulter A. Patient safety: what about the patient? Qual Saf Health Care. 2002;11(1):76-80. https://psnet.ahrq.gov/issue/patient-safety-what-about-patient In this perspective, Vincent and Coulter highlight the need for increased patient involvement in …

8172. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34737/psn-pdf
      November 19, 2015 - First, Do No Harm Part 1: A Case Study of Systems Failure. November 19, 2015 Chicago: Partnership for Patient Safety, Harvard Risk Management Foundation; 2000. https://psnet.ahrq.gov/issue/first-do-no-harm-part-1-case-study-systems-failure This video, produced by the Partnership for Patient Safety and the Harvard …

8173. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48072/psn-pdf
      June 19, 2019 - Independent double checks: worth the effort if used judiciously and properly. June 19, 2019 ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24:1-7. https://psnet.ahrq.gov/issue/independent-double-checks-worth-effort-if-used-judiciously-and-properly Independent double checks can reduce risk of human …

8174. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73238/psn-pdf
      May 12, 2021 - Medical Residents and Burnout May 12, 2021 Coverdale J, West CP, Roberts LW, eds. Acad Med. 2021;96(5):611-769;e14-e21. https://psnet.ahrq.gov/issue/medical-residents-and-burnout Medical training is a demanding experience that impacts a learner’s ability to provide safe care, cope, and remain healthy. This is…

8175. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47722/psn-pdf
      January 23, 2019 - Opening the Door to Change. NHS Safety Culture and the Need for Transformation. January 23, 2019 Newcastle upon Tyne, UK: Care Quality Commission; December 2018. https://psnet.ahrq.gov/issue/opening-door-change-nhs-safety-culture-and-need-transformation The term never events was originally coined to describe rare,…

8176. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837747/psn-pdf
      July 27, 2022 - Measure Dx: A Resource to Identify, Analyze, and Learn from Diagnostic Safety Events. July 27, 2022 Rockville, MD: Agency for Healthcare Research and Quality; July 2022.  AHRQ Publication No. 22- 0038. https://psnet.ahrq.gov/issue/measure-dx-resource-identify-analyze-and-learn-diagnostic-safety-events Diagno…

8177. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838925/psn-pdf
      March 03, 2025 - Improving Quality and Safety in Healthcare. March 3, 2025 Dixon-Woods M, Martin G, eds. Cambridge, UK: Cambridge University Press; 2022-2025. https://psnet.ahrq.gov/issue/improving-quality-and-safety-healthcare Improvement activities are complex initiatives that require synergistic actions by organizations to be s…

8178. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73499/psn-pdf
      July 14, 2021 - Ethics & Governance of Artificial Intelligence for Health. July 14, 2021 Health Ethics & Governance, World Health Organization. Geneva, Switzerland: World Health Organization; 2021.  ISBN: 9789240029200 https://psnet.ahrq.gov/issue/ethics-governance-artificial-intelligence-health Advanced computing t…

8179. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46727/psn-pdf
      August 21, 2021 - Alliance for Innovation on Maternal Health. August 21, 2021 American College of Obstetricians and Gynecologists. https://psnet.ahrq.gov/issue/alliance-innovation-maternal-health This website provides information from a multidisciplinary collaboration whose mission was to support safe health care for pregnant and p…

8180. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867603/psn-pdf
      March 15, 2025 - Request for Information Regarding the Impact of Ageism in Healthcare. January 22, 2025 Request for Information Regarding the Impact of Ageism in Healthcare. Agency for Healthcare Quality and Research. Fed Register. December 27, 2024. 89:105605-105606. https://psnet.ahrq.gov/issue/request-information-regarding-impa…