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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47565/psn-pdf
    April 27, 2019 - Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors. April 27, 2019 Steelman VM, Shaw C, Shine L, et al. Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentinel Events and Contributing Factors. Jt Comm J Qual Patient Saf. 2019;45(4):249…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36178/psn-pdf
    September 30, 2010 - Analysis of surgical errors in closed malpractice claims at 4 liability insurers. September 30, 2010 Rogers SO, Gawande AA, Kwaan M, et al. Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Surgery. 2006;140(1):25-33. https://psnet.ahrq.gov/issue/analysis-surgical-errors-closed-malp…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44134/psn-pdf
    November 06, 2015 - Understanding missed opportunities for more timely diagnosis of cancer in symptomatic patients after presentation. November 6, 2015 Lyratzopoulos G, Vedsted P, Singh H. Understanding missed opportunities for more timely diagnosis of cancer in symptomatic patients after presentation. Br J Cancer. 2015;112 Suppl 1:S…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851915/psn-pdf
    August 02, 2023 - Factor structure and construct validity of a hospital survey on patient safety culture using exploratory factor analysis. August 2, 2023 Falcone ML, Tokac U, Fish AF, et al. Factor structure and construct validity of a hospital survey on patient safety culture using exploratory factor analysis. J Patient Saf. 2023…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843089/psn-pdf
    May 01, 2020 - Direct observation of depression screening: identifying diagnostic error and improving accuracy through unannounced standardized patients. May 1, 2020 Schwartz A, Peskin S, Spiro A, et al. Direct observation of depression screening: identifying diagnostic error and improving accuracy through unannounced standardiz…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45963/psn-pdf
    March 22, 2017 - Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires a Coordinated Public Health Response. March 22, 2017 Boston, MA: National Patient Safety Foundation; March 2017. https://psnet.ahrq.gov/issue/call-action-preventable-health-care-harm-public-health-crisis-and-patient-…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48065/psn-pdf
    June 15, 2019 - Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. June 15, 2019 Patel S, Robertson B, McConachie I. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Anaesthesia. 2019;74(7):904-914. doi:10.1111/anae.14662. https://psnet.ahrq.gov/iss…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73280/psn-pdf
    May 19, 2021 - Rates of serious surgical errors in California and plans to prevent recurrence. May 19, 2021 Cohen AJ, Lui H, Zheng M, et al. Rates of serious surgical errors in California and plans to prevent recurrence. JAMA Netw Open. 2021;4(5):e217058. doi:10.1001/jamanetworkopen.2021.7058. https://psnet.ahrq.gov/issue/rates-…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837769/psn-pdf
    August 03, 2022 - New graduate registered nurses: Risk mitigation strategies to ensure safety and successful transition to practice. August 3, 2022 Smith CJ, DesRoches SL, Street NW, et al. New graduate registered nurses: risk mitigation strategies to ensure safety and successful transition to practice. J Healthc Risk Manag. 2022;4…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43311/psn-pdf
    July 02, 2014 - Some IV medications are diluted unnecessarily in patient care areas, creating undue risk. July 2, 2014 ISMP Medication Safety Alert! Acute Care Edition. June 19, 2014;19:1-5. https://psnet.ahrq.gov/issue/some-iv-medications-are-diluted-unnecessarily-patient-care-areas-creating- undue-risk This newsletter article …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848378/psn-pdf
    May 04, 2023 - Ensuring competency and safety when onboarding newly hired professional staff. May 3, 2023 ISMP Medication Safety Alert! Acute care edition. April 20, 2023;28(8):1-4; May 4, 2023;23(9):1-3. https://psnet.ahrq.gov/issue/ensuring-competency-and-safety-when-onboarding-newly-hired-professional- staff Psychological sa…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34810/psn-pdf
    February 18, 2011 - Should operations be regionalized? The empirical relation between surgical volume and mortality. February 18, 2011 Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized? The empirical relation between surgical volume and mortality. N Engl J Med. 1979;301(25):1364-9. https://psnet.ahrq.gov/issue/should…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74182/psn-pdf
    December 15, 2021 - Honesty and transparency, indispensable to the clinical mission--Parts I-III. December 15, 2021 Brenner MJ, Boothman RC, Rushton CH, et al. Honesty and Transparency, Indispensable to the Clinical Mission—Parts I - III. Otolaryngol Clin North Am. 2021;55(1):43-103. doi:10.1016/j.otc.2021.07.016. https://psnet.ahrq.…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842415/psn-pdf
    January 11, 2023 - Accuracy of spinal anesthesia drug concentrations in mixtures prepared by anesthetists. January 11, 2023 Heesen M, Steuer C, Wiedemeier P, et al. Accuracy of spinal anesthesia drug concentrations in mixtures prepared by anesthetists. J Patient Saf. 2022;18(8):e1226-e1230. doi:10.1097/pts.0000000000001061. https://…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43696/psn-pdf
    April 22, 2015 - Electronic surveillance and pharmacist intervention for vulnerable older inpatients on high-risk medication regimens. April 22, 2015 Peterson JF, Kripalani S, Danciu I, et al. Electronic surveillance and pharmacist intervention for vulnerable older inpatients on high-risk medication regimens. J Am Geriatr Soc. 201…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74211/psn-pdf
    December 22, 2021 - Filling the gaps on the Institute for Safe Medication Practices (ISMP) Do Not Crush List for Immediate-release Products December 22, 2021 Uttaro E, Zhao F, Schweighardt A. Int J Pharm Compd. 2021;25(5):364-371.  https://psnet.ahrq.gov/issue/filling-gaps-institute-safe-medication-practices-ismp-do-not-crush-li…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36552/psn-pdf
    January 12, 2011 - Toward learning from patient safety reporting systems. January 12, 2011 Pronovost P, Thompson DA, Holzmueller CG, et al. Toward learning from patient safety reporting systems. J Crit Care. 2006;21(4):305-15. https://psnet.ahrq.gov/issue/toward-learning-patient-safety-reporting-systems This study reports the initia…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37674/psn-pdf
    June 16, 2011 - An overview of patient safety climate in the VA. June 16, 2011 Hartmann CW, Rosen AK, Meterko M, et al. An overview of patient safety climate in the VA. Health Serv Res. 2008;43(4):1263-84. doi:10.1111/j.1475-6773.2008.00839.x. https://psnet.ahrq.gov/issue/overview-patient-safety-climate-va Measurement of institut…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74748/psn-pdf
    February 09, 2022 - The abrupt expansion of ambulatory telemedicine: implications for patient safety. February 9, 2022 Khoong EC, Sharma AE, Gupta K, et al. The abrupt expansion of ambulatory telemedicine: implications for patient safety. J Gen Intern Med. 2022;37(5):1270-1274. doi:10.1007/s11606-021-07329-9. https://psnet.ahrq.gov/i…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44726/psn-pdf
    January 07, 2016 - The impact of resident duty hour and supervision changes: a review. January 7, 2016 Greenberg WE, Borus JF. The Impact of Resident Duty Hour and Supervision Changes: A Review. Harv Rev Psychiatry. 2016;24(1):69-76. doi:10.1097/HRP.0000000000000061. https://psnet.ahrq.gov/issue/impact-resident-duty-hour-and-supervi…
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