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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73489/psn-pdf
    July 15, 2021 - A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain. July 15, 2021 Kasick RT, Melvin JE, Perera ST, et al. A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain. Diagnosis (Berl). 2021;8(2):209-217. doi:10.1515/dx-2019-0054. https://psnet.ahrq.gov/issue…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73249/psn-pdf
    May 12, 2021 - I-PASS handover system: a decade of evidence demands action. May 12, 2021 Shahian DM. I-PASS handover system: a decade of evidence demands action. BMJ Qual Saf. 2021;30(10):769-774. doi:10.1136/bmjqs-2021-013314. https://psnet.ahrq.gov/issue/i-pass-handover-system-decade-evidence-demands-action The I-PASS structu…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72674/psn-pdf
    January 27, 2021 - The effect of blue-enriched lighting on medical error rate in a university hospital ICU. January 27, 2021 Chen Y, Broman AT, Priest G, et al. The Effect of Blue-Enriched Lighting on Medical Error Rate in a University Hospital ICU. Jt Comm J Qual Saf. 2021;47(3):165-175. doi:10.1016/j.jcjq.2020.11.007. https://psne…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46681/psn-pdf
    April 16, 2018 - Trainee autonomy and patient safety. April 16, 2018 George BC, Dunnington GL, DaRosa DA. Trainee autonomy and patient safety. Ann Surg. 2018;267(5):820-822. doi:10.1097/SLA.0000000000002599. https://psnet.ahrq.gov/issue/trainee-autonomy-and-patient-safety Reduced resident work hours and insufficient senior surgeon…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72761/psn-pdf
    February 17, 2021 - Using ventilator splitters during the COVID-19 pandemic-- letter to health care providers. February 17, 2021 Silver Spring, MD: Division of Industry and Consumer Education, US Food and Drug Administration; February 9. 2021. https://psnet.ahrq.gov/issue/using-ventilator-splitters-during-covid-19-pandemic-letter-hea…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47028/psn-pdf
    May 02, 2018 - Medication errors 2018: the year in review. May 2, 2018 Valentine D, Ingram V, Fobi BNN, Brahmbhatt V. Pharmacy Practice News. April 4, 2018. https://psnet.ahrq.gov/issue/medication-errors-2018-year-review Despite considerable effort, medication errors continue to occur and result in patient harm. Summari…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/764411/psn-pdf
    March 02, 2022 - Nowhere is safe: record number of patients contracted Covid in the hospital in January. March 2, 2022 Levy R, Vestal AJ. Politico. February 19, 2022. https://psnet.ahrq.gov/issue/nowhere-safe-record-number-patients-contracted-covid-hospital-january Transmission of COVID-19 in the health care setting continues to b…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50425/psn-pdf
    September 04, 2019 - Why doctors still offer treatments that may not help. September 4, 2019 Frakt A. New York Times. August 26, 2019. https://psnet.ahrq.gov/issue/why-doctors-still-offer-treatments-may-not-help The slow adoption of improvement innovations is a persistent challenge to high-quality and safe patient care. This newspaper…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45658/psn-pdf
    November 09, 2016 - Hospitals installed more sinks to stop infections. The sinks can make the problem worse. November 9, 2016 Branswell H. STAT. October 25, 2016. https://psnet.ahrq.gov/issue/hospitals-installed-more-sinks-stop-infections-sinks-can-make-problem-worse Hospitals have sought to improve hand hygiene with interventions su…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60750/psn-pdf
    August 06, 2020 - Missed breast cancer: effects of subconscious bias and lesion characteristics. August 6, 2020 Lamb LR, Mohallem Fonseca M, Verma R, et al. Missed breast cancer: effects of subconscious bias and lesion characteristics. RadioGraphics. 2020;40(4):941-960. doi:10.1148/rg.2020190090. https://psnet.ahrq.gov/issue/missed…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854252/psn-pdf
    October 04, 2023 - Standardization and visualization of the surgical time-out. October 4, 2023 Levy BE, Wilt WS, Lantz S, et al. Standardization and visualization of the surgical time-out. J Patient Saf. 2023;19(7):453-459. doi:10.1097/pts.0000000000001156. https://psnet.ahrq.gov/issue/standardization-and-visualization-surgical-time-…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46336/psn-pdf
    August 23, 2017 - Improving the Working Environment for Safe Surgical Care. August 23, 2017 Short-Life Working Group on Hospital Reports. Edinburgh, Scotland: Royal College of Surgeons of Edinburgh; July 31, 2017. https://psnet.ahrq.gov/issue/improving-working-environment-safe-surgical-care Surgical training is demanding and can r…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44333/psn-pdf
    July 15, 2015 - One hospital's initiatives to encourage safe opioid use. July 15, 2015 Surprise JK, Simpson MH. One Hospital's Initiatives to Encourage Safe Opioid Use. J Infus Nurs. 2015;38(4):278-83. doi:10.1097/NAN.0000000000000110. https://psnet.ahrq.gov/issue/one-hospitals-initiatives-encourage-safe-opioid-use This commentar…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60800/psn-pdf
    January 01, 2021 - Changing hospital organisational culture for improved patient outcomes: developing and implementing the Leadership Saves Lives intervention. August 12, 2020 Linnander EL, McNatt Z, Boehmer K, et al. Changing hospital organisational culture for improved patient outcomes: developing and implementing the leadership s…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46384/psn-pdf
    November 14, 2018 - Peggy Lillis Foundation. November 14, 2018 266 12th Street #6, Brooklyn, NY 11215. https://psnet.ahrq.gov/issue/peggy-lillis-foundation Clostridium difficile infections are considered a serious hospital-acquired infection. This grassroots foundation employs educational, policy, and advocacy strategies aimed at red…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837605/psn-pdf
    June 29, 2022 - Under the Skin. The Hidden Toll of Racism on American Lives and on the Health of our Nation. June 29, 2022 Villarosa L. New York, NT: Doubleday: 2022. ISBN 9780385544887.  https://psnet.ahrq.gov/issue/under-skin-hidden-toll-racism-american-lives-and-health-our-nation Health inequities are receiving increased …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74064/psn-pdf
    May 27, 2021 - Achieving zero inequity: lessons learned from patient safety. May 27, 2021 Gandhi TK. NEJM Catalyst. May 27, 2021. https://psnet.ahrq.gov/issue/achieving-zero-inequity-lessons-learned-patient-safety The COVID-19 pandemic has shown a spotlight on bias, disparities, and inequity in the healthcare system. The author…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46253/psn-pdf
    August 28, 2017 - Diagnostic stewardship—leveraging the laboratory to improve antimicrobial use. August 28, 2017 Morgan DJ, Malani P, Diekema DJ. Diagnostic Stewardship-Leveraging the Laboratory to Improve Antimicrobial Use. JAMA. 2017;318(7):607-608. doi:10.1001/jama.2017.8531. https://psnet.ahrq.gov/issue/diagnostic-stewardship-l…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41425/psn-pdf
    June 19, 2012 - Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety? June 19, 2012 Higginson J, Walters R, Fulop NJ. Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety? BMJ Qual Saf. 2012;21(7):576-585. doi:10.1136/bmjqs-2011-00060…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867016/psn-pdf
    October 23, 2024 - An automated, dynamic radiation oncology prescription checking system. October 23, 2024 Pashtan IM, Kosak T, Shin K-Y, et al. An automated, dynamic radiation oncology prescription checking system. Pract Radiat Oncol. 2024;14(4):343-352. doi:10.1016/j.prro.2023.12.002. https://psnet.ahrq.gov/issue/automated-dynamic…

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