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9821. Using Safety-II and resilient healthcare principles to learn from Never Events. | PSNet
      psnet.ahrq.gov/issue/using-safety-ii-and-resilient-healthcare-principles-learn-never-events
      February 20, 2019 - Study Using Safety-II and resilient healthcare principles to learn from Never Events. Citation Text: Anderson JE, Watt AJ. Using Safety-II and resilient healthcare principles to learn from Never Events. Int J Qual Health Care. 2020;32(3):196-203. doi:10.1093/intqhc/mzaa009. Copy Citati…

9822. Multistate point-prevalence survey of health care-associated infections. | PSNet
      psnet.ahrq.gov/issue/multistate-point-prevalence-survey-health-care-associated-infections
      November 14, 2018 - Study Multistate point-prevalence survey of health care-associated infections. Citation Text: Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014;370(13):1198-208. doi:10.1056/NEJMoa1306801. Copy Citation …

9823. Deficient Care of a Patient Who Died by Suicide and Facility Leaders' Response at the Charlie Norwood VA Medical Center in Augusta, Georgia. | PSNet
      psnet.ahrq.gov/issue/deficient-care-patient-who-died-suicide-and-facility-leaders-response-charlie-norwood-va
      November 29, 2023 - Book/Report Deficient Care of a Patient Who Died by Suicide and Facility Leaders' Response at the Charlie Norwood VA Medical Center in Augusta, Georgia. Citation Text: Deficient Care of a Patient Who Died by Suicide and Facility Leaders' Response at the Charlie Norwood VA Medical Center …

9824. Unintended consequences of health care reform: impact of changes in payor mix on patient safety indicators, | PSNet
      psnet.ahrq.gov/issue/unintended-consequences-health-care-reform-impact-changes-payor-mix-patient-safety-indicators
      March 16, 2022 - Study Unintended consequences of health care reform: impact of changes in payor mix on patient safety indicators, Citation Text: Bartholomew AJ, Zeymo A, Chan KS, et al. Unintended consequences of health care reform: impact of changes in payor mix on patient safety indicators,. Ann Surg.…

9825. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36590/psn-pdf
      January 14, 2011 - Interrater agreement with a standard scheme for classifying medication errors. January 14, 2011 Forrey RA, Pedersen CA, Schneider PJ. Interrater agreement with a standard scheme for classifying medication errors. Am J Health Syst Pharm. 2007;64(2):175-81. https://psnet.ahrq.gov/issue/interrater-agreement-standard-…

9826. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50876/psn-pdf
      April 22, 2021 - Veterans Accountability Improvement Act. April 22, 2021 SB 1307, 117th Congress: 2021. https://psnet.ahrq.gov/issue/veterans-accountability-improvement-act Reporting clinicians who exhibit practice behaviors that are detrimental to safety is challenged by system and cultural norms. This legislation aims to strengt…

9827. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46971/psn-pdf
      July 18, 2018 - The Future of NHS Patient Safety Investigation. July 18, 2018 NHS Improvement. London, UK: National Health Service; 2018. https://psnet.ahrq.gov/issue/future-nhs-patient-safety-investigation Organizational processes to investigate adverse care incidents play an important part in generating the learning needed for …

9828. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35348/psn-pdf
      October 26, 2007 - Medical Error. October 26, 2007 National Patient Safety Agency, Medical Defence Union, Medical Protection Society. London, UK: National Patient Safety Agency; 2005. https://psnet.ahrq.gov/issue/medical-error This two-part report focuses on the experience of committing a medical error, along with strategies to red…

9829. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43026/psn-pdf
      March 05, 2014 - Common formats for patient safety data collection and event reporting. March 5, 2014 Federal Register. Rockville, MD: Agency for Healthcare Research and Quality. February 18, 2014;79:9214- 9215. https://psnet.ahrq.gov/issue/common-formats-patient-safety-data-collection-and-event-reporting-1 This announcement call…

9830. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39037/psn-pdf
      July 31, 2012 - "To Err Is Human" Report Retrospective and the Decade Ahead. July 31, 2012 Bonacum D, Corrigan J, Gelinas L, et al. 2009 Annual National Patient Safety Foundation Congress. doi:10.1097/pts.0b013e3181b5cb8a. https://psnet.ahrq.gov/issue/err-human-report-retrospective-and-decade-ahead This publication discusses the…

9831. Healthcare 411. Mistake proofing the health care environment. | PSNet
      psnet.ahrq.gov/issue/healthcare-411-mistake-proofing-health-care-environment
      October 12, 2011 - Government Resource Healthcare 411. Mistake proofing the health care environment. Citation Text: Agency for Healthcare Quality and Research; AHRQ Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy …

9832. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-420
      November 29, 2023 - December 13, 2023 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, repor…

9833. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/863650/psn-pdf
      February 28, 2024 - ABCDEF Bundle + Data Literacy Training, Performance Measurement Tracking, and Performance Feedback February 28, 2024 https://psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking- and-performance Summary To improve patient care and outcomes in the intensive care unit (ICU…

9834. The Other Side | PSNet
      psnet.ahrq.gov/web-mm/other-side
      May 01, 2007 - SPOTLIGHT CASE The Other Side Citation Text: Vincent CA. The Other Side. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

9835. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44180/psn-pdf
      June 21, 2015 - "Never events" and the quest to reduce preventable harm. June 21, 2015 Austin M, Pronovost P. "Never events" and the quest to reduce preventable harm. Jt Comm J Qual Patient Saf. 2015;41(6):279-288. https://psnet.ahrq.gov/issue/never-events-and-quest-reduce-preventable-harm The introduction of the term never event…

9836. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47821/psn-pdf
      May 22, 2019 - Patient Safety. May 22, 2019 National Pharmacy Association; NPA. https://psnet.ahrq.gov/issue/patient-safety-15 This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It i…

9837. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44329/psn-pdf
      September 04, 2016 - Electronic medication reconciliation and medication errors. September 4, 2016 Hron JD, Manzi S, Dionne R, et al. Electronic medication reconciliation and medication errors. Int J Qual Health Care. 2015;27(4):314-9. doi:10.1093/intqhc/mzv046. https://psnet.ahrq.gov/issue/electronic-medication-reconciliation-and-med…

9838. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74167/psn-pdf
      December 08, 2021 - National Patient Safety Board Advocacy Coalition. December 8, 2021 EQT Plaza, 625 Liberty Ave, Ste. 2500, Pittsburgh, PA 15222. https://psnet.ahrq.gov/issue/national-patient-safety-board-advocacy-coalition Centralized reporting and analysis of adverse events in health care is a safety improvement model from the av…

9839. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35219/psn-pdf
      June 12, 2013 - Learning how to learn: compliance with patient safety alerts in the NHS. June 12, 2013 Donaldson L. Chapter in: On the State of Public Health: Annual Report of the Chief Medical Officer. London, UK: Department of Health; 2004. https://psnet.ahrq.gov/issue/learning-how-learn-compliance-patient-safety-alerts-nhs Th…

9840. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45968/psn-pdf
      October 24, 2024 - State of Care. October 24, 2024 Newcastle Upon Tyne, UK: Care Quality Commission; October 2024. https://psnet.ahrq.gov/issue/state-care This website provides access to an annual report that summarizes National Health Service hospital and social care performance across a range of care quality metrics at both the tr…