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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37441/psn-pdf
    November 01, 2012 - Saving Mothers' Lives: Reviewing Maternal Deaths to Make Motherhood Safer—2003–2005. November 1, 2012 Lewis G, ed. London, England: Confidential Enquiry into Maternal and Child Health; 2007. ISBN: 9780953353682. https://psnet.ahrq.gov/issue/saving-mothers-lives-reviewing-maternal-deaths-make-motherhood-safer- 200…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41937/psn-pdf
    September 26, 2016 - Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing? September 26, 2016 ISMP Medication Safety Alert! Acute care edition! November 29, 2012;17:1-3. https://psnet.ahrq.gov/issue/side-tracks-safety-express-interruptions-lead-errors-and-unfinishedwait-what- was-i-doin…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41824/psn-pdf
    November 07, 2012 - Using simulation to teach nursing students and licensed clinicians obstetric emergencies. November 7, 2012 Alderman JT. Using simulation to teach nursing students and licensed clinicians obstetric emergencies. MCN Am J Matern Child Nurs. 2012;37(6):394-400. doi:10.1097/NMC.0b013e318264bbe7. https://psnet.ahrq.gov/…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865588/psn-pdf
    April 17, 2024 - Inattentional blindness in medicine. April 17, 2024 Hults CM, Ding Y, Xie GG, et al. Inattentional blindness in medicine. Cogn Res Princ Implic. 2024;9(1):18. doi:10.1186/s41235-024-00537-x. https://psnet.ahrq.gov/issue/inattentional-blindness-medicine Inattentional blindness occurs when a person is focused so int…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42767/psn-pdf
    November 27, 2013 - Barcode medication administration work-arounds: a systematic review and implications for nurse executives. November 27, 2013 Voshall B, Piscotty R, Lawrence J, et al. Barcode medication administration work-arounds: a systematic review and implications for nurse executives. J Nurs Adm. 2013;43(10):530-535. doi:10.1…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851451/psn-pdf
    July 19, 2023 - Issues and complexities in safety culture assessment in healthcare. July 19, 2023 Ellis LA, Falkland E, Hibbert P, et al. Issues and complexities in safety culture assessment in healthcare. Front Public Health. 2023;11:1217542. doi:10.3389/fpubh.2023.1217542. https://psnet.ahrq.gov/issue/issues-and-complexities-sa…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73898/psn-pdf
    September 29, 2021 - A Thematic Analysis of HSIB's First 22 Investigations.  September 29, 2021 Farnborough, UK: Healthcare Safety Investigation Branch; September 9, 2021. https://psnet.ahrq.gov/issue/thematic-analysis-hsibs-first-22-investigations In-depth failure investigations provide improvement insights for individuals and or…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45185/psn-pdf
    August 03, 2016 - Final Report of the Commission on Care. August 3, 2016 Washington, DC: Commission on Care; June 2016. https://psnet.ahrq.gov/issue/final-report-commission-care The Veterans Affairs health system has recently faced challenges associated with access and quality. Providing an assessment of the current and future stat…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866531/psn-pdf
    August 14, 2024 - The Impact of Artificial Intelligence (AI) on the Safety of Patients. August 14, 2024 Institute for Healthcare Improvement. The Impact of Artificial Intelligence (AI) on the Safety of Patients. . https://psnet.ahrq.gov/issue/impact-artificial-intelligence-ai-safety-patients Artificial intelligence (AI) is rapidly …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35021/psn-pdf
    April 03, 2012 - Health Information Technology Leadership Panel: Final Report. April 3, 2012 Lewin Group: Falls Church, VA; March 2005. https://psnet.ahrq.gov/issue/health-information-technology-leadership-panel-final-report Prepared by the Lewin Group for the Department of Health and Human Services, this 45-page report summarize…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38885/psn-pdf
    August 19, 2009 - Patient safety: Part II. Opportunities for improvement in patient safety. August 19, 2009 Elston DM, Stratman E, Johnson-Jahangir H, et al. Patient safety: Part II. Opportunities for improvement in patient safety. J Am Acad Dermatol. 2009;61(2):193-205; quiz 206. doi:10.1016/j.jaad.2009.04.055. https://psnet.ahrq.…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36506/psn-pdf
    April 19, 2011 - Retrieval medicine: a review and guide for UK practitioners. Part 2: safety in patient retrieval systems. April 19, 2011 Hearns S, Shirley PJ. Retrieval medicine: a review and guide for UK practitioners. Part 2: safety in patient retrieval systems. Emerg Med J. 2006;23(12):943-7. https://psnet.ahrq.gov/issue/retri…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38361/psn-pdf
    January 31, 2011 - IOM: shorten residents' work shifts to reduce fatigue, improve patient safety. January 31, 2011 Kuehn BM. IOM: Shorten residents' work shifts to reduce fatigue, improve patient safety. JAMA. 2009;301(3):259-61. doi:10.1001/jama.2008.940. https://psnet.ahrq.gov/issue/iom-shorten-residents-work-shifts-reduce-fatigue…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42828/psn-pdf
    December 18, 2013 - Texting while doctoring: a patient safety hazard. December 18, 2013 Sinsky CA, Beasley JW. Texting while doctoring: a patient safety hazard. Ann Intern Med. 2013;159(11):782-3. doi:10.7326/0003-4819-159-11-201312030-00012. https://psnet.ahrq.gov/issue/texting-while-doctoring-patient-safety-hazard This commentary r…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40507/psn-pdf
    June 08, 2011 - From research to practice: factors affecting implementation of prospective targeted injury-detection systems. June 8, 2011 Sorensen A, Harrison MI, Kane HL, et al. From research to practice: factors affecting implementation of prospective targeted injury-detection systems. BMJ Qual Saf. 2011;20(6):527-33. doi:10.…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46593/psn-pdf
    November 08, 2017 - Unreadable barcodes and multiple barcodes on packages can lead to errors. November 8, 2017 ISMP Medication Safety Alert! Acute care edition. October 19, 2017;22:1-3. https://psnet.ahrq.gov/issue/unreadable-barcodes-and-multiple-barcodes-packages-can-lead-errors Barcodes can both enhance and degrade the medication …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42477/psn-pdf
    August 07, 2013 - Review into the Quality of Care and Treatment Provided by 14 Hospital Trusts in England: Overview Report. August 7, 2013 Keogh B. London, UK: National Health Service; July 2013. https://psnet.ahrq.gov/issue/review-quality-care-and-treatment-provided-14-hospital-trusts-england- overview-report Outlining findings f…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44565/psn-pdf
    October 14, 2015 - How to use online clinician rating systems. October 14, 2015 Razmaria AA, Livingston EH. JAMA PATIENT PAGE. How to Use Online Clinician Rating Systems. JAMA. 2015;314(13):1418. doi:10.1001/jama.2015.11957. https://psnet.ahrq.gov/issue/how-use-online-clinician-rating-systems Clinician rating sites may not always pr…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37196/psn-pdf
    June 06, 2018 - Fatal 1,000-fold overdoses can occur, particularly in neonates, by transposing mcg and mg. June 6, 2018 ISMP Medication Safety Alert! Acute Care Edition. September 6, 2007;12:1-4. https://psnet.ahrq.gov/issue/fatal-1000-fold-overdoses-can-occur-particularly-neonates-transposing-mcg- and-mg This article analyzes a…

  20. 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…
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