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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43220/psn-pdf
    April 03, 2017 - Patient safety teams recognised at BMJ awards. April 3, 2017 Gulland A. Berwick Patient Safety Team: making the NHS a safer place. BMJ. 2014;348(mar28 1). doi:10.1136/bmj.g2404. https://psnet.ahrq.gov/issue/patient-safety-teams-recognised-bmj-awards The Great Ormond Street Hospital Foundation NHS Trust received th…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43994/psn-pdf
    August 02, 2015 - Using simulation to improve patient safety: dawn of a new era. August 2, 2015 Cheng A, Grant V, Auerbach M. Using simulation to improve patient safety: dawn of a new era. JAMA Pediatr. 2015;169(5):419-20. doi:10.1001/jamapediatrics.2014.3817. https://psnet.ahrq.gov/issue/using-simulation-improve-patient-safety-daw…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42635/psn-pdf
    December 06, 2013 - Improving disclosure and management of medical error—an opportunity to transform the surgeons of tomorrow. December 6, 2013 Tevlin R, Doherty E, Traynor O. Improving disclosure and management of medical error - an opportunity to transform the surgeons of tomorrow. Surgeon. 2013;11(6):338-43. doi:10.1016/j.surge.20…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72711/psn-pdf
    February 03, 2021 - Never Events Analysis of HSIB's National Investigations Report. February 3, 2021 Farnborough, UK: Healthcare Safety Investigation Branch; January 2021.   https://psnet.ahrq.gov/issue/never-events-analysis-hsibs-national-investigations-report Never events provide organizations with motivation to analyze a…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74703/psn-pdf
    January 26, 2022 - Research to improve diagnosis: time to study the real world. January 26, 2022 Ranji SR, Thomas EJ. Research to improve diagnosis: time to study the real world. BMJ Qual Saf. 2022;31(4):255-258. doi:10.1136/bmjqs-2021-014071. https://psnet.ahrq.gov/issue/research-improve-diagnosis-time-study-real-world Diagnostic …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37347/psn-pdf
    March 28, 2012 - Recognition and management of potential drug-drug interactions in patients on internal medicine wards. March 28, 2012 Vonbach P, Dubied A, Beer JH, et al. Recognition and management of potential drug-drug interactions in patients on internal medicine wards. Eur J Clin Pharmacol. 2007;63(11):1075-83. https://psnet.…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60258/psn-pdf
    April 22, 2020 - Operational Measurement of Diagnostic Safety: State of the Science. April 22, 2020 Singh H, Bradford A, Goeschel C. Rockville, MD: Agency for Healthcare Research and Quality; April 2020. AHRQ Publication No. 20-0040-1-EF. https://psnet.ahrq.gov/issue/operational-measurement-diagnostic-safety-state-science This is…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45949/psn-pdf
    July 11, 2017 - Beyond medication reconciliation: the correct medication list. July 11, 2017 Rose AJ, Fischer SH, Paasche-Orlow MK. Beyond Medication Reconciliation: The Correct Medication List. JAMA. 2017;317(20):2057-2058. doi:10.1001/jama.2017.4628. https://psnet.ahrq.gov/issue/beyond-medication-reconciliation-correct-medicati…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43126/psn-pdf
    April 23, 2014 - Safe and appropriate use of insulin and other antihyperglycemic agents in hospital. April 23, 2014 Cornish W. Safe and appropriate use of insulin and other antihyperglycemic agents in hospital. Can J Diabetes. 2014;38(2):94-100. doi:10.1016/j.jcjd.2014.01.002. https://psnet.ahrq.gov/issue/safe-and-appropriate-use-…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855002/psn-pdf
    November 01, 2023 - Temporarily holding medication orders safely in order to prevent patient harm. November 1, 2023 ISMP Medication Safety Alert! Acute care edition. October 19, 2023;28(21):1-4. https://psnet.ahrq.gov/issue/temporarily-holding-medication-orders-safely-order-prevent-patient-harm Process disconnects can cause administr…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45749/psn-pdf
    January 11, 2017 - Instrument count sheets and set reviews as patient safety tools. January 11, 2017 Spear J. Instrument Count Sheets and Set Reviews as Patient Safety Tools. AORN J. 2016;104(6):588- 592. doi:10.1016/j.aorn.2016.10.007. https://psnet.ahrq.gov/issue/instrument-count-sheets-and-set-reviews-patient-safety-tools Inaccu…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43372/psn-pdf
    April 13, 2016 - A case for improving measurement of intraoperative iatrogenic injuries. April 13, 2016 Paruch JL, Ko CY, Bilimoria KY. A case for improving measurement of intraoperative iatrogenic injuries. JAMA Surg. 2014;149(9):887-8. doi:10.1001/jamasurg.2013.5237. https://psnet.ahrq.gov/issue/case-improving-measurement-intrao…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45567/psn-pdf
    October 12, 2016 - Insulin Pens Devices. October 12, 2016 Am J Health Syst Pharm. 2016;73(19 suppl 5);s1-s47. https://psnet.ahrq.gov/issue/insulin-pens-devices As a high-alert medication, insulin has the potential to result in serious patient harm if administered incorrectly. Articles in this special issue discuss recommendations de…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41285/psn-pdf
    June 01, 2012 - Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge for geriatric patients. June 1, 2012 Cornu P, Steurbaut S, Leysen T, et al. Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46071/psn-pdf
    March 20, 2018 - Evaluating situation awareness: an integrative review. March 20, 2018 Orique SB, Despins L. Evaluating Situation Awareness: An Integrative Review. West J Nurs Res. 2018;40(3):388-424. doi:10.1177/0193945917697230. https://psnet.ahrq.gov/issue/evaluating-situation-awareness-integrative-review Situation awareness in…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45221/psn-pdf
    July 18, 2016 - When less is better, but physicians are afraid not to intervene. July 18, 2016 Esserman L. When Less Is Better, but Physicians Are Afraid Not to Intervene. JAMA Intern Med. 2016;176(7):888-9. doi:10.1001/jamainternmed.2016.2257. https://psnet.ahrq.gov/issue/when-less-better-physicians-are-afraid-not-intervene Bia…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43395/psn-pdf
    July 30, 2014 - The current and ideal state of anatomic pathology patient safety. July 30, 2014 Raab SS. The current and ideal state of anatomic pathology patient safety. MLO Med Lab Obs. 2014;46(6):8-10. https://psnet.ahrq.gov/issue/current-and-ideal-state-anatomic-pathology-patient-safety This commentary illustrates the proces…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39695/psn-pdf
    July 21, 2010 - The impact of the 80-hour work week on appropriate resident case coverage. July 21, 2010 Shin S, Britt R, Doviak M, et al. The Impact of the 80-Hour Work Week on Appropriate Resident Case Coverage. Journal of Surgical Research. 2009;162(1). doi:10.1016/j.jss.2009.12.003. https://psnet.ahrq.gov/issue/impact-80-hour…

  19. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/worksheet.docx
    May 01, 2017 - AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership AHRQ Safety Program for Perinatal Care Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership Purpose: To enhance communication and shared problem solving between clinic…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45150/psn-pdf
    October 13, 2018 - Pain as the neglected patient safety concern: five years on. October 13, 2018 Twycross A, Forgeron P, Chorne J, et al. Pain as the neglected patient safety concern: Five years on. J Child Health Care. 2016;20(4):537-541. doi:10.1177/1367493516643422. https://psnet.ahrq.gov/issue/pain-neglected-patient-safety-conce…
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