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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73691/psn-pdf
    September 08, 2021 - Pump up the volume: tips for increasing error reporting and decreasing patient harm. September 8, 2021 ISMP Medication Safety Alert! Acute care edition. August 26, 2021;26(17);1-5.  https://psnet.ahrq.gov/issue/pump-volume-tips-increasing-error-reporting-and-decreasing-patient-harm Error reporting is an essen…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60604/psn-pdf
    June 17, 2020 - The limits of current A.I. in health care: patient safety policing in hospitals. June 17, 2020 Furrow BR. NE Univ Law Rev. 2020;12(1):1-55. https://psnet.ahrq.gov/issue/limits-current-ai-health-care-patient-safety-policing-hospitals Artificial intelligence (AI) has the potential to improve the use of big data to e…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45923/psn-pdf
    April 19, 2017 - Huddles and debriefings: improving communication on labor and delivery. April 19, 2017 McQuaid-Hanson E, Pian-Smith MCM. Huddles and Debriefings: Improving Communication on Labor and Delivery. Anesthesiol Clin. 2017;35(1):59-67. doi:10.1016/j.anclin.2016.09.006. https://psnet.ahrq.gov/issue/huddles-and-debriefings…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43819/psn-pdf
    July 16, 2015 - Intercepting wrong-patient orders in a computerized provider order entry system. July 16, 2015 Green RA, Hripcsak G, Salmasian H, et al. Intercepting wrong-patient orders in a computerized provider order entry system. Ann Emerg Med. 2015;65(6):679-686.e1. doi:10.1016/j.annemergmed.2014.11.017. https://psnet.ahrq.g…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837593/psn-pdf
    June 29, 2022 - Adverse event reporting priorities: an integrative review. June 29, 2022 Falcone ML, Van Stee SK, Tokac U, et al. Adverse event reporting priorities: an integrative review. J Patient Saf. 2022;18(4):e727-e740. doi:10.1097/pts.0000000000000945. https://psnet.ahrq.gov/issue/adverse-event-reporting-priorities-integrat…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37754/psn-pdf
    May 14, 2008 - Potentially inappropriate medication use in hospitalized elders. May 14, 2008 Rothberg MB, Pekow PS, Liu F, et al. Potentially inappropriate medication use in hospitalized elders. J Hosp Med. 2008;3(2):91-102. doi:10.1002/jhm.290. https://psnet.ahrq.gov/issue/potentially-inappropriate-medication-use-hospitalized-e…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47645/psn-pdf
    April 17, 2019 - When a nurse is prosecuted for a fatal medical mistake, does it make medicine safer? April 17, 2019 Gordon M. Health Shots. National Public Radio. April 10, 2019. https://psnet.ahrq.gov/issue/when-nurse-prosecuted-fatal-medical-mistake-does-it-make-medicine-safer Punitive responses to medical errors persist despit…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60766/psn-pdf
    August 05, 2020 - Dermatology faces a reckoning: lack of darker skin in textbooks and journals harms care for patients of color. August 5, 2020 McFarling UL. Stat. July 21, 2020. https://psnet.ahrq.gov/issue/dermatology-faces-reckoning-lack-darker-skin-textbooks-and-journals-harms- care-patients-color Dermatologists rely on v…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40985/psn-pdf
    December 07, 2011 - Implementing the World Health Organization surgical safety checklist: a model for future perioperative initiatives. December 7, 2011 Styer KA, Ashley SW, Schmidt I, et al. Implementing the World Health Organization surgical safety checklist: a model for future perioperative initiatives. AORN J. 2011;94(6):590-8. …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851461/psn-pdf
    July 19, 2023 - Patient safety 2.0: slaying dragons, not just investigating them. July 19, 2023 Card AJ. Patient safety 2.0: slaying dragons, not just investigating them. J Patient Saf. 2023;19(6):394-395. doi:10.1097/pts.0000000000001140. https://psnet.ahrq.gov/issue/patient-safety-20-slaying-dragons-not-just-investigating-them …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45792/psn-pdf
    December 20, 2017 - Reevaluation of diagnosis in adults with physician- diagnosed asthma. December 20, 2017 Aaron SD, Vandemheen KL, FitzGerald M, et al. Reevaluation of Diagnosis in Adults With Physician- Diagnosed Asthma. JAMA. 2017;317(3):269-279. doi:10.1001/jama.2016.19627. https://psnet.ahrq.gov/issue/reevaluation-diagnosis-adu…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38945/psn-pdf
    November 25, 2009 - The negative impact of nurse-physician disruptive behavior on patient safety: a review of the literature. November 25, 2009 Saxton R, Hines T, Enriquez M. The negative impact of nurse-physician disruptive behavior on patient safety: a review of the literature. J Patient Saf. 2009;5(3):180-183. doi:10.1097/pts.0b013…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/839327/psn-pdf
    December 05, 2024 - The National Healthcare System Action Alliance for Patient and Workforce Safety. December 5, 2024 US Department of Health and Human Services. https://psnet.ahrq.gov/issue/national-healthcare-system-action-alliance-advance-patient-safety The large system change required to reduce patient harm requires multi-stakeho…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836761/psn-pdf
    March 16, 2022 - Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance. March 16, 2022 Padula WV, Armstrong DG, Goldman DP. Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance. Mayo Clin Proc. 2022;97(2):221-224. doi:10.1016/j.mayocp.2021.1…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47851/psn-pdf
    May 22, 2019 - Communication and Resolution After an Adverse Health Care Incident. May 22, 2019 Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201. https://psnet.ahrq.gov/issue/communication-and-resolution-after-adverse-health-care-incident Communication-and-resolution mechanisms are seen as important approache…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855107/psn-pdf
    January 01, 2019 - Foundations of Safety Science: a century of understanding accidents and disasters. January 1, 2019 Dekker S. Taylor & Francis Group, Boca Raton, FL: CRC Press; 2019. ISBN:  9781138481787. https://psnet.ahrq.gov/issue/foundations-safety-science-century-understanding-accidents-and-disasters Safety science p…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46483/psn-pdf
    October 04, 2017 - Fall Prevention in Hospitals Training Program. October 4, 2017 Rockville, MD: Agency for Healthcare Research and Quality; 2017. https://psnet.ahrq.gov/issue/fall-prevention-hospitals-training-program Falls are a primary focus of quality and patient safety improvement efforts in hospitals. This training program pro…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45273/psn-pdf
    October 13, 2018 - Using an inpatient portal to engage families in pediatric hospital care. October 13, 2018 Kelly MM, Hoonakker P, Dean SM. Using an inpatient portal to engage families in pediatric hospital care. J Am Med Inform Assoc. 2017;24(1):153-161. doi:10.1093/jamia/ocw070. https://psnet.ahrq.gov/issue/using-inpatient-portal…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/862151/psn-pdf
    February 07, 2024 - Taking up the challenge to improve name and role recognition in the operating room. February 7, 2024 Thota B, Rabinowitz A, Guttman OT. Taking up the challenge to improve name and role recognition in the operating room. J Patient Saf. 2024;20(1):45-47. doi:10.1097/pts.0000000000001177. https://psnet.ahrq.gov/issue…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74848/psn-pdf
    February 16, 2022 - Patients for Patient Safety US. February 16, 2022 404.510.8787; info@pfps.us https://psnet.ahrq.gov/issue/patients-patient-safety-us Patient safety improvement has made progress but more can be done. This organization supports community efforts in the United States to engage policymakers in work toward aligning ef…
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