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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72751/psn-pdf
    February 17, 2021 - The critical need for nursing education to address the diagnostic process. February 17, 2021 Gleason KT, Harkless G, Stanley J, et al. The critical need for nursing education to address the diagnostic process. Nurs Outlook. 2021;69(3):362-369. doi:10.1016/j.outlook.2020.12.005. https://psnet.ahrq.gov/issue/critica…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46160/psn-pdf
    June 07, 2017 - ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults. June 7, 2017 Horsham, PA: Institute for Safe Medication Practices; May 2017. https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-subcutaneous-insulin-use-adults Insulin is a widely used medication that can contribute to serious patien…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46444/psn-pdf
    December 19, 2017 - Nil per os orders for imaging: a teachable moment. December 19, 2017 Wickerham AL, Schultz EJ, Lewine EB. Nil per Os Orders for Imaging: A Teachable Moment. JAMA Intern Med. 2017;177(11):1670-1671. doi:10.1001/jamainternmed.2017.3943. https://psnet.ahrq.gov/issue/nil-os-orders-imaging-teachable-moment Patients are…
  4. 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…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45486/psn-pdf
    September 14, 2016 - Addressing nurse fatigue to promote safety and health: joint responsibilities of registered nurses and employers to reduce risks. September 14, 2016 Silver Spring, MD: American Nurses Association; September 2014. https://psnet.ahrq.gov/issue/addressing-nurse-fatigue-promote-safety-and-health-joint-responsibilities…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47943/psn-pdf
    May 20, 2019 - Governing the safety of artificial intelligence in healthcare. May 20, 2019 Macrae C. Governing the safety of artificial intelligence in healthcare. BMJ Qual Saf. 2019;28(6):495-498. doi:10.1136/bmjqs-2019-009484. https://psnet.ahrq.gov/issue/governing-safety-artificial-intelligence-healthcare The unintended risk…
  7. www.ahrq.gov/patients-consumers/patient-involvement/navigating-the-health-care-system.html
    September 01, 2015 - Navigating the Health Care System After having led AHRQ for a decade, Dr. Carolyn Clancy left the Agency in 2013 to begin work as Assistant Deputy Undersecretary for Health, Patient Safety, Quality, and Value at the Veterans Administration. First and foremost a physician, Dr. Clancy was at AHRQ for 23 years. …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837024/psn-pdf
    May 04, 2022 - The potential for leveraging machine learning to filter medication alerts. May 4, 2022 Liu S, Kawamoto K, Del Fiol G, et al. The potential for leveraging machine learning to filter medication alerts. J Am Med Inform Assoc. 2022;29(5):891-899. doi:10.1093/jamia/ocab292. https://psnet.ahrq.gov/issue/potential-levera…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48068/psn-pdf
    June 12, 2019 - Health Professions Education. June 12, 2019 Dhaliwal G, Olson APJ, Singhal G, eds. Diagnosis (Berl). 2019;6(2):75-185. https://psnet.ahrq.gov/issue/health-professions-education Clinical and educational environments are increasingly focusing on improving diagnosis. This special issue explores an overarching approac…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72591/psn-pdf
    December 23, 2020 - Bias and racism teaching rounds at an academic medical center. December 23, 2020 Capers Q, Bond DA, Nori US. Bias and racism teaching rounds at an academic medical center. Chest. 2020;158(6):2688-2694. doi:10.1016/j.chest.2020.08.2073. https://psnet.ahrq.gov/issue/bias-and-racism-teaching-rounds-academic-medical-c…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40385/psn-pdf
    May 21, 2019 - A comprehensive obstetrics patient safety program improves safety climate and culture. May 21, 2019 Pettker CM, Thung SF, Raab CA, et al. A comprehensive obstetrics patient safety program improves safety climate and culture. Am J Obstet Gynecol. 2011;204(3):216.e1-6. doi:10.1016/j.ajog.2010.11.004. https://psnet.a…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47718/psn-pdf
    March 20, 2019 - Impact of patient safety culture on missed nursing care and adverse patient events. March 20, 2019 Hessels AJ, Paliwal M, Weaver SH, et al. Impact of Patient Safety Culture on Missed Nursing Care and Adverse Patient Events. J Nurs Care Qual. 2019;34(4):287-294. doi:10.1097/NCQ.0000000000000378. https://psnet.ahrq.…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33927/psn-pdf
    June 23, 2015 - Errors, incidents and accidents in anaesthetic practice. June 23, 2015 Runciman WB, Sellen A, Webb RK, et al. The Australian Incident Monitoring Study. Errors, incidents and accidents in anaesthetic practice. Anaesth Intensive Care. 1993;21(5):506-19. https://psnet.ahrq.gov/issue/errors-incidents-and-accidents-anae…
  14. 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…
  15. 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…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39218/psn-pdf
    January 13, 2010 - Prolonged hospital stay and the resident duty hour rules of 2003. January 13, 2010 Silber JH, Rosenbaum PR, Rosen AK, et al. Prolonged Hospital Stay and the Resident Duty Hour Rules of 2003. Med Care. 2009;47(12). doi:10.1097/mlr.0b013e3181adcbff. https://psnet.ahrq.gov/issue/prolonged-hospital-stay-and-resident-d…
  17. 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…
  18. 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…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35176/psn-pdf
    June 23, 2009 - Mapping changes in surgical mortality over 9 years by peer review audit. June 23, 2009 Thompson A, Ashraf Z, Burton H, et al. Mapping changes in surgical mortality over 9 years by peer review audit. Br J Surg. 2005;92(11):1449-52. https://psnet.ahrq.gov/issue/mapping-changes-surgical-mortality-over-9-years-peer-re…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836833/psn-pdf
    March 30, 2022 - As a nurse faces prison for a deadly error, her colleagues worry: could I be next? March 30, 2022 Kelman B. Kaiser Health News. March 22, 2022 https://psnet.ahrq.gov/issue/nurse-faces-prison-deadly-error-her-colleagues-worry-could-i-be-next Criminalization of medical mistakes typifies the blame-focused approach pa…