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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39182/psn-pdf
    May 22, 2019 - ACOG Committee Opinion No. 447: patient safety in obstetrics and gynecology. May 22, 2019 Improvement AC of O and GCC on PS and Q. ACOG Committee Opinion No. 447: Patient safety in obstetrics and gynecology. Obstet Gynecol. 2009;114(6):1424-7. doi:10.1097/AOG.0b013e3181c6f90e. https://psnet.ahrq.gov/issue/acog-com…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40502/psn-pdf
    January 01, 2020 - New 2012 National Patient Safety Goal - catheter- associated urinary tract infection (CAUTI). June 1, 2011 Joint Commission. https://psnet.ahrq.gov/issue/new-2012-national-patient-safety-goal-catheter-associated-urinary-tract- infection-cauti This announcement reveals the new National Patient Safety Goal for 2012…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45544/psn-pdf
    December 19, 2016 - Prescribing errors that cause harm. December 19, 2016 Rider BB, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. September 2016;13:81-91. https://psnet.ahrq.gov/issue/prescribing-errors-cause-harm Prescribing errors can have harmful results. Analyzing prescribing error reports submitted over a 12- year period, t…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42228/psn-pdf
    October 08, 2013 - Cognitive diagnostic error in internal medicine. October 8, 2013 Van den Berge K, Mamede S. Cognitive diagnostic error in internal medicine. Eur J Intern Med. 2013;24(6):525-9. doi:10.1016/j.ejim.2013.03.006. https://psnet.ahrq.gov/issue/cognitive-diagnostic-error-internal-medicine This review discusses how confir…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39807/psn-pdf
    December 29, 2014 - Perspectives in quality: designing the WHO Surgical Safety Checklist. December 29, 2014 Weiser TG, Haynes AB, Lashoher A, et al. Perspectives in quality: designing the WHO Surgical Safety Checklist. Int J Qual Health Care. 2010;22(5):365-70. doi:10.1093/intqhc/mzq039. https://psnet.ahrq.gov/issue/perspectives-qual…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60948/psn-pdf
    September 23, 2020 - Without an 'ounce of empathy': their stories show the dangers of being Black and pregnant. September 23, 2020 Ramaswamy SV. Rockland/Westchester Journal News. September 9, 2020. https://psnet.ahrq.gov/issue/without-ounce-empathy-their-stories-show-dangers-being-black-and-pregnant Implicit and explicit biases …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851660/psn-pdf
    July 26, 2023 - From aviation to pediatric surgery. July 26, 2023 Arredondo Montero J, Bardají Pascual C. From aviation to pediatric surgery. Clin Pediatr (Phila). 2024;63(4):557-559. doi:10.1177/00099228231176631. https://psnet.ahrq.gov/issue/aviation-pediatric-surgery Human factors strategies are increasingly applied in health …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40865/psn-pdf
    September 12, 2016 - A review of current and emerging approaches to address failure-to-rescue. September 12, 2016 Taenzer AH, Pyke JB, McGrath SP. A review of current and emerging approaches to address failure-to- rescue. Anesthesiology. 2011;115(2):421-31. doi:10.1097/ALN.0b013e318219d633. https://psnet.ahrq.gov/issue/review-current-…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50878/psn-pdf
    February 05, 2020 - The role of racism as a core patient safety issue. February 5, 2020 Feeley D, Torres T. The role of racism as a core patient safety issue. Healthcare Executive. 2020;35(1):58- 61. https://psnet.ahrq.gov/issue/role-racism-core-patient-safety-issue A variety of biases can reduce the effectiveness and safety of care.…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39576/psn-pdf
    September 25, 2010 - Taking Care of Myself: A Guide for When I Leave the Hospital. September 25, 2010 Rockville, MD: Agency for Healthcare Research and Quality; April 2010. AHRQ Publication No. 10-0059. https://psnet.ahrq.gov/issue/taking-care-myself-guide-when-i-leave-hospital This guide provides patients with information they need t…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45990/psn-pdf
    August 24, 2022 - Medication Safety Certificate Program. August 24, 2022 American Society of Health-System Pharmacists, Institute for Safe Medication Practices. https://psnet.ahrq.gov/issue/medication-safety-certificate-program Leadership commitment to reduce medication errors can help address this safety problem. This certificate …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44875/psn-pdf
    March 02, 2016 - "Teach-back" from a patient's perspective. March 2, 2016 Miller S, Lattanzio M, Cohen S. "Teach-back" from a patient's perspective. Nursing (Brux). 2016;46(2):63-4. doi:10.1097/01.NURSE.0000476249.18503.f5. https://psnet.ahrq.gov/issue/teach-back-patients-perspective The teach-back method, having patients repeat i…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38453/psn-pdf
    January 02, 2017 - A multidisciplinary team approach to retained foreign objects. January 2, 2017 Cima RR, Kollengode A, Storsveen AS, et al. A multidisciplinary team approach to retained foreign objects. Jt Comm J Qual Saf. 2009;35(3):123-132. https://psnet.ahrq.gov/issue/multidisciplinary-team-approach-retained-foreign-objects Th…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60264/psn-pdf
    January 14, 2021 - COVID-19 Content. ISMP Medication Safety Alert! January 14, 2021 March 2020--January 2021. https://psnet.ahrq.gov/issue/special-editions-covid-19-ismp-medication-safety-alert Medication safety is improved through the sharing of frontline improvement experiences and concerns. These articles share recommendations to…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60262/psn-pdf
    April 22, 2020 - COVID-19 exposes potential gaps in PPE training, effectiveness. April 22, 2020 Ault A. Medscape Medical News. April 6, 2020. https://psnet.ahrq.gov/issue/covid-19-exposes-potential-gaps-ppe-training-effectiveness Training is essential to ensure the safe use of equipment. This article discusses how the incorrect us…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40868/psn-pdf
    October 19, 2011 - Simulation to enhance patient safety: why aren't we there yet? October 19, 2011 Aggarwal R, Darzi A. Simulation to enhance patient safety: why aren't we there yet? Chest. 2011;140(4):854-858. doi:10.1378/chest.11-0728. https://psnet.ahrq.gov/issue/simulation-enhance-patient-safety-why-arent-we-there-yet Discussin…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41053/psn-pdf
    December 30, 2014 - Time to accelerate integration of human factors and ergonomics in patient safety. December 30, 2014 Gurses AP, Ozok A, Pronovost P. Time to accelerate integration of human factors and ergonomics in patient safety. BMJ Qual Saf. 2012;21(4):347-51. doi:10.1136/bmjqs-2011-000421. https://psnet.ahrq.gov/issue/time-acc…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846165/psn-pdf
    March 15, 2023 - Do no unconscious harm. March 15, 2023 Ortega RP. Do no unconscious harm. Science. 2023;379(6635):870-873. doi:10.1126/science.adh3698. https://psnet.ahrq.gov/issue/do-no-unconscious-harm Implicit biases can degrade decision making as they impact heuristics, test result interpretation, and patient/physician commun…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39558/psn-pdf
    May 26, 2010 - ReCASTing the RCA: an improved model for performing root cause analyses. May 26, 2010 Pham JC, Kim GR, Natterman JP, et al. ReCASTing the RCA: An Improved Model for Performing Root Cause Analyses. American Journal of Medical Quality. 2010;25(3). doi:10.1177/1062860609359533. https://psnet.ahrq.gov/issue/recasting-…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45338/psn-pdf
    July 20, 2016 - Understanding models of error and how they apply in clinical practice. July 20, 2016 Garfield S, Franklin BD. Pharm J. June 14, 2016. https://psnet.ahrq.gov/issue/understanding-models-error-and-how-they-apply-clinical-practice Human error and fallibility are a part of health care delivery that can be exacerbated b…

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