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5961. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37173/psn-pdf
      January 02, 2017 - Eliminating adverse drug events at Ascension Health. January 2, 2017 Butler K, Mollo P, Gale JL, et al. Eliminating adverse drug events at Ascension Health. Jt Comm J Qual Patient Saf. 2007;33(9):527-36. https://psnet.ahrq.gov/issue/eliminating-adverse-drug-events-ascension-health The authors describe an initiativ…

5962. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36312/psn-pdf
      October 26, 2010 - The intensive care unit, patient safety, and the Agency for Healthcare Research and Quality. October 26, 2010 Clancy CM. The intensive care unit, patient safety, and the Agency for Healthcare Research and Quality. Am J Med Qual. 2006;21(5):348-51. https://psnet.ahrq.gov/issue/intensive-care-unit-patient-safety-and…

5963. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42600/psn-pdf
      September 18, 2013 - Oral medications inadvertently given via the intravenous route. September 18, 2013 Shah-Mohammadi AR, Gaunt MJ. PA-PSRS Patient Saf Advis. September 2013;10:85-91. https://psnet.ahrq.gov/issue/oral-medications-inadvertently-given-intravenous-route Analyzing data submitted to the Pennsylvania Patient Safety Reporti…

5964. NIOSH Training for Nurses on Shift Work and Long Work Hours | PSNet
      psnet.ahrq.gov/training-catalog/niosh-training-nurses-shift-work-and-long-work-hours
      September 15, 2025 - NIOSH Training for Nurses on Shift Work and Long Work Hours Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Organization: Organization National Institute for Occupational Safety and Health (…

5965. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40406/psn-pdf
      February 13, 2018 - Critical conversations: a call for a nonprocedural "time out." February 13, 2018 Sehgal NL, Fox M, Sharpe B, et al. Critical conversations: a call for a nonprocedural "time out". J Hosp Med. 2011;6(4):225-30. doi:10.1002/jhm.853. https://psnet.ahrq.gov/issue/critical-conversations-call-nonprocedural-time-out This…

5966. In Conversation with…William B. Weeks, MD, MBA | PSNet
      psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
      May 01, 2009 - we found that when there were complications at the hospital, the profit margin for the hospital was reduced

5967. In Conversation with...Peter J. Pronovost, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
      October 01, 2010 - ) and a checklist guiding the activities surrounding the insertion of central venous catheters that reduced

5968. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43491/psn-pdf
      January 01, 2015 - The systems approach to medicine: controversy and misconceptions. December 9, 2014 Dekker SWA, Leveson NG. The systems approach to medicine: controversy and misconceptions. BMJ Qual Saf. 2015;24(1):7-9. doi:10.1136/bmjqs-2014-003106. https://psnet.ahrq.gov/issue/systems-approach-medicine-controversy-and-misconcept…

5969. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43055/psn-pdf
      May 01, 2017 - AHRQ's Safety Program for Ambulatory Surgery. May 1, 2017 Health Research & Educational Trust. Rockville, MD: Agency for Healthcare Research and Quality; May 2017. AHRQ Publication No. 16(17)-0019-1-EF. https://psnet.ahrq.gov/issue/ahrqs-safety-program-ambulatory-surgery This report provides information about a na…

5970. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50727/psn-pdf
      December 11, 2019 - Your diagnosis was wrong. Could doctor bias have been a factor? December 11, 2019 Glicksman E. Washington Post. November 17, 2019. https://psnet.ahrq.gov/issue/your-diagnosis-was-wrong-could-doctor-bias-have-been-factor Unconscious assumptions and biases are known contributors to poor decision-making. This news st…

5971. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41411/psn-pdf
      October 19, 2012 - Minnesota Hospital Association Statewide Project: SAFE from FALLS. October 19, 2012 Apold J, Quigley PA. Minnesota Hospital Association Statewide Project: SAFE from FALLS. J Nurs Care Qual. 2012;27(4):299-306. doi:10.1097/NCQ.0b013e3182599d1b. https://psnet.ahrq.gov/issue/minnesota-hospital-association-statewide-p…

5972. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37653/psn-pdf
      May 14, 2008 - Getting boards on board: engaging governing boards in quality and safety.  May 14, 2008 Conway JB. Getting boards on board: engaging governing boards in quality and safety. Jt Comm J Qual Saf. 2008;34(4):214-220. https://psnet.ahrq.gov/issue/getting-boards-board-engaging-governing-boards-quality-and-safety This a…

5973. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41955/psn-pdf
      January 09, 2013 - Making Medical Devices Safer at Home. January 9, 2013 Consumer Updates. Silver Spring, MD: US Food and Drug Administration; December 12, 2012. https://psnet.ahrq.gov/issue/making-medical-devices-safer-home Highlighting concerns associated with patients' use of medical devices at home, such as difficulty understand…

5974. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42364/psn-pdf
      September 18, 2013 - The pursuit of better diagnostic performance: a human factors perspective. September 18, 2013 Henriksen K, Brady J. The pursuit of better diagnostic performance: a human factors perspective. BMJ Qual Saf. 2013;22(Suppl 2):ii1-ii5. doi:10.1136/bmjqs-2013-001827. https://psnet.ahrq.gov/issue/pursuit-better-diagnosti…

5975. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36431/psn-pdf
      March 28, 2011 - Using the internet to deliver education on drug safety. March 28, 2011 Franklin B, O'Grady K, Parr J, et al. Using the internet to deliver education on drug safety. Qual Saf Health Care. 2006;15(5):329-33. https://psnet.ahrq.gov/issue/using-internet-deliver-education-drug-safety The project team implemented a web-…

5976. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43318/psn-pdf
      July 02, 2014 - Sign up to Safety. July 2, 2014 National Health Service. https://psnet.ahrq.gov/issue/sign-safety Through a coordinated effort to set goals and devise plans to improve safety in hospitals, the Sign up to Safety campaign aims to prevent 6000 patient deaths in the next 3 years in National Health Service facilities.…

5977. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40696/psn-pdf
      December 01, 2011 - Rapid response systems: a prospective study of response times. December 1, 2011 Adelstein B-A, Piza MA, Nayyar V, et al. Rapid response systems: a prospective study of response times. J Crit Care. 2011;26(6):635.e11-8. doi:10.1016/j.jcrc.2011.03.013. https://psnet.ahrq.gov/issue/rapid-response-systems-prospective-…

5978. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38341/psn-pdf
      April 02, 2009 - CPOE: it don't come easy. April 2, 2009 Anderson HJ. CPOE: it don't come easy. Health Data Manag. 2009;17(1):18-20, 22, 24 passim. https://psnet.ahrq.gov/issue/cpoe-it-dont-come-easy Although shifting from paper-based or verbal orders to computerized physician order entry (CPOE) systems could reduce medical errors…

5979. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40568/psn-pdf
      June 29, 2011 - Tubing misconnections: normalization of deviance. June 29, 2011 Simmons D, Symes L, Guenter P, et al. Tubing misconnections: normalization of deviance. Nutr Clin Pract. 2011;26(3):286-293. doi:10.1177/0884533611406134. https://psnet.ahrq.gov/issue/tubing-misconnections-normalization-deviance Analyzing published ca…

5980. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40903/psn-pdf
      March 08, 2015 - Does your patient really understand? March 8, 2015 Huff C. Does your patient really understand? Hospitals & health networks. 2011;85(10):34-5, 37-8, 2. https://psnet.ahrq.gov/issue/does-your-patient-really-understand This article discusses health literacy and describes an initiative to reduce gaps in understanding …