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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837038/psn-pdf
    May 04, 2022 - Mind the Implementation Gap. The Persistence of Avoidable Harm in the NHS. May 4, 2022 London UK: Patient Safety Learning: 2022. https://psnet.ahrq.gov/issue/mind-implementation-gap-persistence-avoidable-harm-nhs Unsafe care affects a wide range of individuals and organizations physically, emotionally, and financi…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60040/psn-pdf
    March 11, 2020 - Shifting the Mindset: A Closer Look at Hospital Complaints. March 11, 2020 Newcastle upon Tyne, UK: Healthwatch; January 2020. https://psnet.ahrq.gov/issue/shifting-mindset-closer-look-hospital-complaints Organizations need to do more than report and collect complaint data to realize improvements based on what is…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35786/psn-pdf
    May 07, 2007 - When Things Go Wrong: Responding to Adverse Events. May 7, 2007 Boston, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2006. https://psnet.ahrq.gov/issue/when-things-go-wrong-responding-adverse-events This consensus paper of the Harvard-affiliated hospitals was prepared by clinicians, risk manage…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/864385/psn-pdf
    April 05, 2024 - Common Formats for Patient Safety Data Collection. March 13, 2024 Agency for Healthcare Research and Quality. Fed Register. Mar 6, 2024;89(45);15992. https://psnet.ahrq.gov/issue/common-formats-patient-safety-data-collection A standard system for voluntary reporting to patient safety organizations improves measurem…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34731/psn-pdf
    July 08, 2016 - Crossing the Quality Chasm: A New Health System for the 21st Century. July 8, 2016 Committee on Quality of Health Care in America, Institute of Medicine. Washington DC: National Academies Press; 2001. ISBN: 9780309072809. https://psnet.ahrq.gov/issue/crossing-quality-chasm-new-health-system-21st-century Following…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/864352/psn-pdf
    March 13, 2024 - Creating a just culture in the perioperative setting. March 13, 2024 Hooven K, Altmiller G. Creating a just culture in the perioperative setting. AORN J. 2024;119(2):152-160. doi:10.1002/aorn.14074. https://psnet.ahrq.gov/issue/creating-just-culture-perioperative-setting Fear of retaliation by leaders or colleague…

  7. Detection of Safety Hazards | PSNet

    psnet.ahrq.gov/primer/detection-safety-hazards
    March 30, 2022 - Detection of Safety Hazards Citation Text: Detection of Safety Hazards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…

  8. Emergency department image interpretation accuracy: the influence of immediate reporting by radiology. | PSNet

    psnet.ahrq.gov/issue/emergency-department-image-interpretation-accuracy-influence-immediate-reporting-radiology
    November 09, 2022 - Study Emergency department image interpretation accuracy: the influence of immediate reporting by radiology. Citation Text: Snaith B, Hardy M. Emergency department image interpretation accuracy: The influence of immediate reporting by radiology. Int Emerg Nurs. 2014;22(2):63-8. doi:10.10…

  9. Evaluating a handheld decision support device in pediatric intensive care settings. | PSNet

    psnet.ahrq.gov/issue/evaluating-handheld-decision-support-device-pediatric-intensive-care-settings
    January 18, 2023 - Study Evaluating a handheld decision support device in pediatric intensive care settings. Citation Text: Evaluating a handheld decision support device in pediatric intensive care settings. Reynolds TL, DeLucia PR, Esquibel KA, et al. JAMIA Open. 2019;2:49-61. Copy Citation …

  10. The need for risk profiling in patient safety. | PSNet

    psnet.ahrq.gov/issue/need-risk-profiling-patient-safety
    August 08, 2010 - Commentary The need for risk profiling in patient safety. Citation Text: Donaldson LJ, Noble DJ. The need for risk profiling in patient safety. J Patient Saf. 2010;6(3):125-7. doi:10.1097/PTS.0b013e3181ed73a3. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote…

  11. Learning from mistakes in New Zealand hospitals: what else do we need besides "no-fault"? | PSNet

    psnet.ahrq.gov/issue/learning-mistakes-new-zealand-hospitals-what-else-do-we-need-besides-no-fault
    March 16, 2022 - Study Learning from mistakes in New Zealand hospitals: what else do we need besides "no-fault"? Citation Text: Soleimani F. Learning from mistakes in New Zealand hospitals: what else do we need besides "no-fault"? N Z Med J. 2006;119(1239):U2099. Copy Citation Format: Goo…

  12. Treatment errors in healthcare: a safety climate approach. | PSNet

    psnet.ahrq.gov/issue/treatment-errors-healthcare-safety-climate-approach
    July 13, 2010 - Study Treatment errors in healthcare: a safety climate approach. Citation Text: Naveh E, Katz-Navon T, Stern Z. Treatment errors in healthcare: a safety climate approach. . Manage Sci. 2005;51(6):948-960. doi:10.1287/mnsc.1050.0372. Copy Citation Format: DOI Google Schol…

  13. A middle ground on public accountability. | PSNet

    psnet.ahrq.gov/issue/middle-ground-public-accountability
    March 02, 2011 - Commentary Classic A middle ground on public accountability. Citation Text: Lee TH, Meyer GS, Brennan TA. A middle ground on public accountability. N Engl J Med. 2004;350(23):2409-2412. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X…

  14. The reliability of AHRQ Common Format Harm Scales in rating patient safety events. | PSNet

    psnet.ahrq.gov/issue/reliability-ahrq-common-format-harm-scales-rating-patient-safety-events
    January 23, 2017 - Study The reliability of AHRQ Common Format Harm Scales in rating patient safety events. Citation Text: Williams TL, Szekendi MK, Pavkovic S, et al. The reliability of AHRQ Common Format Harm Scales in rating patient safety events. J Patient Saf. 2015;11(1):52-59. doi:10.1097/PTS.0b013e3…

  15. Prevention of fatal opioid overdose. | PSNet

    psnet.ahrq.gov/issue/prevention-fatal-opioid-overdose
    October 03, 2018 - Commentary Prevention of fatal opioid overdose. Citation Text: Beletsky L, Rich JD, Walley AY. Prevention of fatal opioid overdose. JAMA. 2012;308(18):1863-4. doi:10.1001/jama.2012.14205. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML…

  16. Analysis of laboratory critical value reporting at a large academic medical center. | PSNet

    psnet.ahrq.gov/issue/analysis-laboratory-critical-value-reporting-large-academic-medical-center
    December 05, 2013 - Study Analysis of laboratory critical value reporting at a large academic medical center. Citation Text: Dighe AS, Rao A, Coakley AB, et al. Analysis of laboratory critical value reporting at a large academic medical center. Am J Clin Pathol. 2006;125(5):758-64. Copy Citation For…

  17. Close calls in patient safety: should we be paying closer attention? | PSNet

    psnet.ahrq.gov/issue/close-calls-patient-safety-should-we-be-paying-closer-attention
    November 08, 2013 - Commentary Close calls in patient safety: should we be paying closer attention? Citation Text: Wu AW, Marks CM. Close calls in patient safety: should we be paying closer attention? CMAJ. 2013;185(13):1119-20. doi:10.1503/cmaj.130014. Copy Citation Format: DOI Google Schol…

  18. Translating patient safety legislation into health care practice. | PSNet

    psnet.ahrq.gov/issue/translating-patient-safety-legislation-health-care-practice
    February 15, 2011 - Commentary Translating patient safety legislation into health care practice. Citation Text: Rabinowitz ABK, Clarke JR, Marella WM, et al. Translating patient safety legislation into health care practice. Jt Comm J Qual Patient Saf. 2006;32(12):676-681. Copy Citation Format: …

  19. IV Push Gap Analysis Tool (GAT) helps uncover national priorities for safe injection practices. | PSNet

    psnet.ahrq.gov/issue/iv-push-gap-analysis-tool-gat-helps-uncover-national-priorities-safe-injection-practices
    August 14, 2019 - Newspaper/Magazine Article IV Push Gap Analysis Tool (GAT) helps uncover national priorities for safe injection practices. Citation Text: IV Push Gap Analysis Tool (GAT) helps uncover national priorities for safe injection practices. ISMP Medication Safety Alert! Acute Care Edition. Augu…

  20. NCPDP Recommendations and Guidance for Standardizing the Dosing Designations on Prescription Container Labels of Oral Liquid Medications Version 1.0. | PSNet

    psnet.ahrq.gov/issue/ncpdp-recommendations-and-guidance-standardizing-dosing-designations-prescription-container
    September 09, 2020 - Book/Report NCPDP Recommendations and Guidance for Standardizing the Dosing Designations on Prescription Container Labels of Oral Liquid Medications Version 1.0. Citation Text: NCPDP Recommendations and Guidance for Standardizing the Dosing Designations on Prescription Container Labels o…
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