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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50729/psn-pdf
    December 11, 2019 - Improving Diagnostic Quality & Safety/Reducing Diagnostic Error: Measurement Considerations. December 11, 2019 Washington DC; National Quality Forum: October 28, 2019. https://psnet.ahrq.gov/issue/improving-diagnostic-quality-safetyreducing-diagnostic-error-measurement- considerations Efforts to track, understand…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47954/psn-pdf
    August 07, 2019 - Special Issue on Resilience Engineering and High Reliability Organizations. August 7, 2019 Wears RL, Roberts KH, eds. Safety Sci. 2019;117;458-533. https://psnet.ahrq.gov/issue/special-issue-resilience-engineering-and-high-reliability-organizations Resilience is an organizational characteristic that enables indivi…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867450/psn-pdf
    January 08, 2025 - Advancing Health Care Safety for All. January 8, 2025 Advancing Health Care Safety for All. Centers for Medicare and Medicaid Services. 2024. https://psnet.ahrq.gov/issue/advancing-health-care-safety-all As one element of a national program to improve care quality, the Centers for Medicare and Medicaid Services (C…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34979/psn-pdf
    June 22, 2009 - The WHO World Alliance for Patient Safety: a new challenge or an old one neglected? June 22, 2009 Edwards R. The WHO World Alliance for Patient Safety: a new challenge or an old one neglected? Drug Saf. 2005;28(5):379-86. https://psnet.ahrq.gov/issue/who-world-alliance-patient-safety-new-challenge-or-old-one-negle…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45503/psn-pdf
    October 29, 2017 - All CLEAR? Preparing for IT downtime. October 29, 2017 Kashiwagi DT, Sexton MD, Graves ES, et al. All CLEAR? Preparing for IT Downtime. Am J Med Qual. 2017;32(5):547-551. doi:10.1177/1062860616667546. https://psnet.ahrq.gov/issue/all-clear-preparing-it-downtime Due to the increasing integration of health care proc…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842432/psn-pdf
    January 11, 2023 - Medication errors: the year in review: January through December 2021. January 11, 2023 Pharmacy Practice News Special Edition. December 13, 2022: 43-54. https://psnet.ahrq.gov/issue/medication-errors-year-review-january-through-december-2021 Medication errors continue to occur despite long-standing efforts to redu…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847057/psn-pdf
    April 05, 2023 - Implement strategies to prevent persistent medication errors and hazards. April 5, 2023 ISMP Medication Safety Alert! Acute care edition. March 23, 2023;28(6):1-4. https://psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards Medication mistakes are recognized contributors to p…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73225/psn-pdf
    May 05, 2021 - Black or 'other'? Doctors may be relying on race to make decisions about your health. May 5, 2021 Smith J, Spodak C. CNN. April 25, 2021. https://psnet.ahrq.gov/issue/black-or-other-doctors-may-be-relying-race-make-decisions-about-your-health Race-adjusted decision making tools perpetuate the potential for diagnos…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48041/psn-pdf
    July 10, 2019 - Accuracy of computer-aided diagnosis of melanoma: a meta-analysis. July 10, 2019 Dick V, Sinz C, Mittlböck M, et al. Accuracy of Computer-Aided Diagnosis of Melanoma. JAMA Dermatol. 2019;155(11):1291-1299. doi:10.1001/jamadermatol.2019.1375. https://psnet.ahrq.gov/issue/accuracy-computer-aided-diagnosis-melanoma-m…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50758/psn-pdf
    December 18, 2019 - Still Not Safe: Patient Safety and the Middle-Managing of American Medicine. December 18, 2019 Wears R, Sutcliffe K. New York, NY: Oxford University Press; 2019. ISBN: 9780190271268. https://psnet.ahrq.gov/issue/still-not-safe-patient-safety-and-middle-managing-american-medicine The modern patient safety movement …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60742/psn-pdf
    July 29, 2020 - Doctors and dentists still flooding U.S. with opioid prescriptions. July 29, 2020 Mann B. Doctors and dentists still flooding U.S. with opioid prescriptions. National Public Radio. 2020;July 17. https://psnet.ahrq.gov/issue/doctors-and-dentists-still-flooding-us-opioid-prescriptions Despite efforts to reduce opio…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43778/psn-pdf
    April 22, 2015 - Meet the cancer patient in room 52: his name is Joseph, but call him Joe. April 22, 2015 Sun LH. https://psnet.ahrq.gov/issue/meet-cancer-patient-room-52-his-name-joseph-call-him-joe This newspaper article reports on a pilot program which involved redesigning intensive care unit processes to enhance staff knowled…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50594/psn-pdf
    October 30, 2019 - Pharmacist linkage in care transitions: from academic medical center to community. October 30, 2019 Bloodworth LS, Malinowski SS, Lirette ST, et al. Pharmacist linkage in care transitions: from academic medical center to community. J Am Pharm Assoc . 2019;59(6):896-904. doi:10.1016/j.japh.2019.08.011. https://psne…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47386/psn-pdf
    September 19, 2018 - Active-shooter response at a health care facility. September 19, 2018 Inaba K, Eastman AL, Jacobs LM, et al. Active-Shooter Response at a Health Care Facility. N Engl J Med. 2018;379(6):583-586. doi:10.1056/NEJMms1800582. https://psnet.ahrq.gov/issue/active-shooter-response-health-care-facility Physical and verbal…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39119/psn-pdf
    November 25, 2009 - Effect of a weight-based prescribing method within an electronic health record on prescribing errors. November 25, 2009 Ginzburg R, Barr WB, Harris M, et al. Effect of a weight-based prescribing method within an electronic health record on prescribing errors. Am J Health Syst Pharm. 2009;66(22):2037-41. doi:10.214…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47925/psn-pdf
    August 21, 2019 - Second victims and mindfulness: a systematic review. August 21, 2019 S Miller C, Scott SD, Beck M. Second victims and mindfulness: a systematic review. J Patient Saf Risk Manag. 2019;24(3):108-117. doi:10.1177/2516043519838176. https://psnet.ahrq.gov/issue/second-victims-and-mindfulness-systematic-review The secon…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72598/psn-pdf
    January 01, 2021 - Hospital medication errors: a cross sectional study. December 23, 2020 ISAACS AN, Ch'ng K, DELHIWALE N, et al. Hospital medication errors: a cross-sectional study. Int J Qual Health Care. 2021;33(1):mzaa136. doi:10.1093/intqhc/mzaa136. https://psnet.ahrq.gov/issue/hospital-medication-errors-cross-sectional-study R…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43379/psn-pdf
    August 14, 2014 - Unit of measurement used and parent medication dosing errors. August 14, 2014 Yin S, Dreyer BP, Ugboaja DC, et al. Unit of measurement used and parent medication dosing errors. Pediatrics. 2014;134(2):e354-61. doi:10.1542/peds.2014-0395. https://psnet.ahrq.gov/issue/unit-measurement-used-and-parent-medication-dosi…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60192/psn-pdf
    April 01, 2020 - Effective Reporting Could Improve Safe Use of Electronic Health Records. April 1, 2020 Philadelphia, PA: Pew Charitable Trusts; March 2020. https://psnet.ahrq.gov/issue/effective-reporting-could-improve-safe-use-electronic-health-records Electronic health records both enhance and challenge the safety of care proce…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38420/psn-pdf
    February 18, 2009 - Effect of short-term pretrial practice on surgical proficiency in simulated environments: a randomized trial of the "preoperative warm-up" effect. February 18, 2009 Kahol K, Satava RM, Ferrara JJ, et al. Effect of Short-Term Pretrial Practice on Surgical Proficiency in Simulated Environments: A Randomized Trial of…

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