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6021. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60162/psn-pdf
      March 25, 2020 - Patient Safety Improvement Act of 2020. March 25, 2020 SB 3380. 116th Congress (2020). https://psnet.ahrq.gov/issue/patient-safety-improvement-act-2020 This bill submits amendments to existing US federal law to strengthen state-organized efforts to improve health care-associated infection control efforts, pediatri…

6022. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60167/psn-pdf
      April 12, 2024 - Discharge Planning and Transitions of Care March 25, 2020 Bajorek SA, McElroy V. Discharge Planning and Transitions of Care. PSNet [internet]. 2020. https://psnet.ahrq.gov/primer/discharge-planning-and-transitions-care Background Transitions of care refer to the movement of patients between different healthcare se…

6023. Mixup Beyond the Medication Label | PSNet
      psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
      June 01, 2014 - Mixup Beyond the Medication Label Citation Text: Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote …

6024. Back to Basics | PSNet
      psnet.ahrq.gov/web-mm/back-basics
      July 13, 2010 - Back to Basics Citation Text: Hellman R. Back to Basics. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

6025. XL or Smaller? | PSNet
      psnet.ahrq.gov/web-mm/xl-or-smaller
      September 13, 2017 - XL or Smaller? Citation Text: Kozer E. XL or Smaller?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

6026. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/863641/psn-pdf
      February 28, 2024 - Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training February 28, 2024 Haugstetter M, Hines S, Sousane Z, et al. Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork…

6027. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49680/psn-pdf
      March 01, 2013 - Pathologic Mistake March 1, 2013 Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/pathologic-mistake The Case A 32-year-old previously healthy woman experienced abdominal pain and bloating for 6 months. The discomfort worsened with eating. After losing 15 pounds …

6028. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33763/psn-pdf
      March 01, 2014 - How Does Infection Prevention Fit Into a Safety Program? March 1, 2014 Huang SS. How Does Infection Prevention Fit Into a Safety Program? PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program Perspective In 1999, the Institute of Medicine (IOM) released the To …

6029. Fumbled Handoff | PSNet
      psnet.ahrq.gov/web-mm/fumbled-handoff
      September 01, 2006 - Fumbled Handoff Citation Text: Vidyarthi A. Fumbled Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

6030. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867805/psn-pdf
      February 26, 2025 - The safe surgery checklist is another example of an intervention that has clearly reduced risk, although

6031. Patient Safety: A Perspective from Office Practice | PSNet
      psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
      May 01, 2009 - we found that when there were complications at the hospital, the profit margin for the hospital was reduced

6032. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50771/psn-pdf
      May 29, 2024 - AHRQ Health Literacy Universal Precautions Toolkit. 3rd edition. May 29, 2024 Brach C, ed. Rockville, MD: Agency for Healthcare Research and Quality; March 2024. AHRQ Publication No. 15-0023-EF. https://psnet.ahrq.gov/issue/ahrq-health-literacy-universal-precautions-toolkit-2nd-edition The AHRQ Health Literacy Un…

6033. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45932/psn-pdf
      May 18, 2017 - Polypharmacy. May 18, 2017 Zagaria MAE, ed. Clin Geriatr Med. 2017;33:153-292. https://psnet.ahrq.gov/issue/polypharmacy Older patients are likely to be prescribed multiple medications, which can increase risks. Articles in this special issue explore polypharmacy in a variety of care settings and provide tactics f…

6034. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41506/psn-pdf
      October 12, 2012 - Preventable errors in organ transplantation: an emerging patient safety issue? October 12, 2012 Ison MG, Holl JL, Ladner D. Preventable errors in organ transplantation: an emerging patient safety issue? Am J Transplant. 2012;12(9):2307-12. doi:10.1111/j.1600-6143.2012.04139.x. https://psnet.ahrq.gov/issue/preventa…

6035. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48026/psn-pdf
      July 10, 2019 - Network of Patient Safety Databases. July 10, 2019 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/network-patient-safety-databases The Patient Safety Organization (PSO) program seeks to gather and analyze nonidentifiable patient safety incident data to track concerns and reduce risks. Thi…

6036. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48190/psn-pdf
      June 17, 2024 - APSF Stoelting Conference. June 17, 2024 Anesthesia Patient Safety Foundation. Markell Conference Center, Somerville, MA, September 4–5, 2024. https://psnet.ahrq.gov/issue/apsf-stoelting-conference Anesthesia is a high-risk activity that has achieved safety successes. This hybrid conference explored topics related…

6037. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39585/psn-pdf
      June 09, 2010 - Bar code technology and medication administration error. June 9, 2010 Young J, Slebodnik M, Sands L. Bar Code Technology and Medication Administration Error. J Patient Saf. 2010;6(2):115-120. doi:10.1097/pts.0b013e3181de35f7. https://psnet.ahrq.gov/issue/bar-code-technology-and-medication-administration-error This…

6038. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73173/psn-pdf
      April 21, 2021 - Racism and Health. April 21, 2021 Centers for Disease Control and Prevention. https://psnet.ahrq.gov/issue/racism-and-health Ethnic and social inequities have a substantial impact on the safety and effectiveness of health care. This US Centers for Disease Control and Prevention (CDC) initiative provides access to …

6039. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44226/psn-pdf
      November 03, 2015 - The Patient Survival Handbook. November 3, 2015 Powell SM, Stone RD. Peachtree City, GA: Synensis; 2015. https://psnet.ahrq.gov/issue/patient-survival-handbook Engaging patients in their care is increasingly advocated as a way to improve safety. This book recommends actions for patients and families to reduce risk…

6040. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42311/psn-pdf
      May 29, 2013 - We know what they did wrong, but not why: the case for 'frame-based' feedback. May 29, 2013 Rudolph JW, Raemer D, Shapiro J. We knowwhatthey did wrong, but notwhy: the case for ‘frame-based’ feedback. Clin Teach. 2013;10(3):186-189. doi:10.1111/j.1743-498x.2012.00636.x. https://psnet.ahrq.gov/issue/we-know-what-th…