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psnet.ahrq.gov/node/43515/psn-pdf
July 03, 2016 - Targeting improvements in patient safety at a large
academic center: an institutional handoff curriculum for
graduate medical education.
July 3, 2016
Allen S, Caton C, Cluver J, et al. Targeting improvements in patient safety at a large academic center: an
institutional handoff curriculum for graduate medical educ…
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psnet.ahrq.gov/node/38326/psn-pdf
January 14, 2009 - Results of a medication reconciliation survey from the
2006 Society of Hospital Medicine national meeting.
January 14, 2009
Clay BJ, Halasyamani L, Stucky ER, et al. Results of a medication reconciliation survey from the 2006
Society of Hospital Medicine national meeting. J Hosp Med. 2008;3(6). doi:10.1002/jhm.370.…
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psnet.ahrq.gov/node/46326/psn-pdf
October 18, 2017 - Surgical Patient Safety: A Case-Based Approach.
October 18, 2017
Stahel PF, ed. New York, NY: McGraw-Hill Education/Medical; 2017. ISBN: 9780071842631.
https://psnet.ahrq.gov/issue/surgical-patient-safety-case-based-approach
Surgical residency can be a stressful learning experience. This textbook provides an introd…
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psnet.ahrq.gov/node/44074/psn-pdf
November 16, 2015 - Investigating Clinical Incidents in the NHS.
November 16, 2015
Sixth Report of Session 2014–15. House of Commons Public Administration Select Committee. London,
England: The Stationery Office; March 27, 2015. Publication HC 886.
https://psnet.ahrq.gov/issue/investigating-clinical-incidents-nhs
Applying evidence ge…
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psnet.ahrq.gov/node/36242/psn-pdf
March 06, 2019 - Your attention please... designing effective warnings.
March 6, 2019
ISMP Medication Safety Alert! Acute care edition. February 28, 2019.
https://psnet.ahrq.gov/issue/your-attention-please-designing-effective-warnings
Medication warnings inform providers and patients about risks associated with medication use. As w…
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psnet.ahrq.gov/node/42698/psn-pdf
December 04, 2013 - A structured judgement method to enhance mortality
case note review: development and evaluation.
December 4, 2013
Hutchinson A, Coster JE, Cooper KL, et al. A structured judgement method to enhance mortality case note
review: development and evaluation. BMJ Qual Saf. 2013;22(12). doi:10.1136/bmjqs-2013-001839.
htt…
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psnet.ahrq.gov/node/46963/psn-pdf
April 18, 2018 - A Just Culture Guide.
April 18, 2018
NHS Improvement. London, UK: National Health Service; March 15, 2018.
https://psnet.ahrq.gov/issue/just-culture-guide
Although focusing on system failure has been highlighted as key to improving patient safety, individual
behaviors must also be recognized as contributors to ris…
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psnet.ahrq.gov/node/41644/psn-pdf
September 12, 2012 - The cost of harm and savings through safety: using
simulated patients for leadership decision support.
September 12, 2012
Denham CR, Guilloteau FR. The cost of harm and savings through safety: using simulated patients for
leadership decision support. J Patient Saf. 2012;8(3):89-96. doi:10.1097/PTS.0b013e318258cb25.…
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psnet.ahrq.gov/node/43166/psn-pdf
May 07, 2014 - Are med school grads prepared to practice medicine?
May 7, 2014
Angus S, Vu R, Halvorsen AJ, et al. What skills should new internal medicine interns have in july? A
national survey of internal medicine residency program directors. Academic medicine : journal of the
Association of American Medical Colleges. 2014;89(…
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psnet.ahrq.gov/node/35502/psn-pdf
May 27, 2011 - Medication errors: a prospective cohort study of hand-
written and computerised physician order entry in the
intensive care unit.
May 27, 2011
Shulman R, Singer M, Goldstone J, et al. Medication errors: a prospective cohort study of hand-written and
computerised physician order entry in the intensive care unit. Cr…
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psnet.ahrq.gov/node/44389/psn-pdf
August 19, 2015 - A method of addressing proprietary name similarity for
US prescription drugs.
August 19, 2015
Stockbridge MD, Taylor K. A Method of Addressing Proprietary Name Similarity for US Prescription Drugs.
Ther Innov Regul Sci. 2015;49(4). doi:10.1177/2168479015570331.
https://psnet.ahrq.gov/issue/method-addressing-propri…
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psnet.ahrq.gov/node/47218/psn-pdf
January 09, 2019 - The accuracy of medical dispatch—a systematic review.
January 9, 2019
Bohm K, Kurland L. The accuracy of medical dispatch - a systematic review. Scand J Trauma Resusc
Emerg Med. 2018;26(1):94. doi:10.1186/s13049-018-0528-8.
https://psnet.ahrq.gov/issue/accuracy-medical-dispatch-systematic-review
Medical dispatch i…
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psnet.ahrq.gov/node/40195/psn-pdf
February 02, 2011 - Mock trial at 2009 RSNA annual meeting: jury exonerates
radiologist for failure to communicate abnormal
finding—but...
February 2, 2011
Berlin L. Mock trial at 2009 RSNA annual meeting: Jury exonerates radiologist for failure to communicate
abnormal finding--but.. Radiology. 2010;257(3):836-45. doi:10.1148/radiol.…
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psnet.ahrq.gov/node/35809/psn-pdf
February 25, 2015 - Stories from the sharp end: case studies in safety
improvement.
February 25, 2015
McCarthy D; Blumenthal D. Milbank Q. 2006;84(1):165-200
https://psnet.ahrq.gov/issue/stories-sharp-end-case-studies-safety-improvement
This study shares the efforts of six different health care organizations in implementing intervent…
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psnet.ahrq.gov/node/45070/psn-pdf
October 03, 2017 - When There's Harm in the Hospital: Can Transparency
Replace "Deny and Defend"?
October 3, 2017
National Health Policy Forum. Washington, DC: George Washington University. March 11, 2016.
https://psnet.ahrq.gov/issue/when-theres-harm-hospital-can-transparency-replace-deny-and-defend
This report provides the insight…
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psnet.ahrq.gov/node/846168/psn-pdf
March 15, 2023 - Now is the time to routinely ask patients about safety.
March 15, 2023
Gandhi TK. Now Is the Time to Routinely Ask Patients About Safety. Jt Comm J Qual Patient Saf.
2023;49(4):235-236. doi:10.1016/j.jcjq.2023.01.009.
https://psnet.ahrq.gov/issue/now-time-routinely-ask-patients-about-safety
Safety event reporting …
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psnet.ahrq.gov/node/865598/psn-pdf
April 17, 2024 - Guardians of grafts: reducing medication errors in
transplant recipients.
April 17, 2024
ISMP Medication Safety Alert! Acute care. April 4, 2024;29(7):1-4.
https://psnet.ahrq.gov/issue/guardians-grafts-reducing-medication-errors-transplant-recipients
Safe medication therapy for transplant patients is complex and h…
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psnet.ahrq.gov/node/48043/psn-pdf
October 01, 2023 - Health Services Safety Investigations Body.
October 1, 2023
Lytchett House, 13 Freeland Park, Wareham Road, Poole, Dorset, BH16 6FA.
https://psnet.ahrq.gov/issue/health-services-safety-investigations-body
Independent investigations examine system weaknesses in health care to inform improvement, reduce risk,
and pr…
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psnet.ahrq.gov/node/836920/psn-pdf
April 13, 2022 - Family support role in hospital rapid response teams: a
scoping review.
April 13, 2022
Howlett O, Gleeson R, Jackson L, et al. Family support role in hospital rapid response teams: a scoping
review. JBI Evid Synth. 2022;20(8):2001-2024. doi:10.11124/jbies-21-00189.
https://psnet.ahrq.gov/issue/family-support-role-…
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psnet.ahrq.gov/node/43677/psn-pdf
November 19, 2014 - Reporting and Learning Systems for Medication Errors:
The Role of Pharmacovigilance Centres.
November 19, 2014
Bencheikh SR, Cousins D, Benabdallah G, et al. Geneva, Switzerland: World Health Organization; October
2014. ISBN: 9789241507943.
https://psnet.ahrq.gov/issue/reporting-and-learning-systems-medication-err…