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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47359/psn-pdf
    October 10, 2018 - Is there evidence of a July effect among patients undergoing hysterectomy surgery? October 10, 2018 Varma S, Mehta A, Hutfless S, et al. Is there evidence of a July effect among patients undergoing hysterectomy surgery? Am J Obstet Gynecol. 2018;219(2):176.e1-176.e9. doi:10.1016/j.ajog.2018.05.033. https://psnet.a…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46544/psn-pdf
    September 12, 2018 - Interventions to improve follow-up of laboratory test results pending at discharge: a systematic review. September 12, 2018 Whitehead NS, Williams L, Meleth S, et al. Interventions to Improve Follow-Up of Laboratory Test Results Pending at Discharge: A Systematic Review. J Hosp Med. 2018. doi:10.12788/jhm.2944. ht…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35218/psn-pdf
    August 07, 2018 - Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety. August 7, 2018 Scobie S, Thomson R. London, UK : National Patient Safety Agency; 2005. https://psnet.ahrq.gov/issue/building-memory-preventing-harm-reducing-risks-and-improving-patient-safety Created in 2001 to institute changes in he…
  4. psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
    November 25, 2020 - event within the first month after hospital discharge, and many of these are preventable. 16 Case 2 is representative
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60552/psn-pdf
    June 03, 2020 - Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. June 3, 2020 Verbeek JH, Rajamaki B, Ijaz S, et al. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthc…
  6. psnet.ahrq.gov/primer/personal-health-literacy
    October 31, 2023 - The only nationally representative survey of health literacy, conducted in 2003, tested adults' ability
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50768/psn-pdf
    December 27, 2019 - In a few places PFACs are required to be representative of the people who live in the healthcare organization
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33599/psn-pdf
    August 30, 2023 - The only nationally representative survey of health literacy, conducted in 2003, tested adults' ability
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46060/psn-pdf
    October 31, 2017 - Do hospitals support second victims? Collective insights from patient safety leaders in Maryland. October 31, 2017 Edrees HH, Morlock L, Wu AW. Do Hospitals Support Second Victims? Collective Insights From Patient Safety Leaders in Maryland. Jt Comm J Qual Saf. 2017;43(9):471-483. doi:10.1016/j.jcjq.2017.01.008. h…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35571/psn-pdf
    April 06, 2011 - Overestimation of clinical diagnostic performance caused by low necropsy rates. April 6, 2011 Shojania KG, Burton EC, McDonald KM, et al. Overestimation of clinical diagnostic performance caused by low necropsy rates. Qual Saf Health Care. 2005;14(6):408-13. https://psnet.ahrq.gov/issue/overestimation-clinical-dia…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39987/psn-pdf
    September 20, 2011 - Fall prevention in acute care hospitals: a randomized trial. September 20, 2011 Dykes PC, Carroll DL, Hurley A, et al. Fall prevention in acute care hospitals: a randomized trial. JAMA. 2010;304(17):1912-1918. doi:10.1001/jama.2010.1567. https://psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-t…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44043/psn-pdf
    September 20, 2017 - Incident learning in pursuit of high reliability: implementing a comprehensive, low-threshold reporting program in a large, multisite radiation oncology department. September 20, 2017 Gabriel PE, Volz E, Bergendahl HW, et al. Incident learning in pursuit of high reliability: implementing a comprehensive, low-thre…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46559/psn-pdf
    December 22, 2018 - Effect of promoting high-quality staff interactions on fall prevention in nursing homes: a cluster-randomized trial. December 22, 2018 Colón-Emeric CS, Corazzini K, McConnell ES, et al. Effect of Promoting High-Quality Staff Interactions on Fall Prevention in Nursing Homes: A Cluster-Randomized Trial. JAMA Intern M…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45760/psn-pdf
    February 08, 2017 - Safe practices for copy and paste in the EHR. Systematic review, recommendations, and novel model for health IT collaboration. February 8, 2017 Tsou AY, Lehmann CU, Michel J, et al. Safe Practices for Copy and Paste in the EHR. Systematic Review, Recommendations, and Novel Model for Health IT Collaboration. Appl C…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44165/psn-pdf
    May 27, 2015 - Unplanned return to theater: a quality of care and risk management index? May 27, 2015 Pujol N, Merrer J, Lemaire B, et al. Unplanned return to theater: A quality of care and risk management index? Orthop Traumatol Surg Res. 2015;101(4):399-403. doi:10.1016/j.otsr.2015.03.013. https://psnet.ahrq.gov/issue/unplanne…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42379/psn-pdf
    August 08, 2013 - Prevalence and nature of adverse medical device events in hospitalized children. August 8, 2013 Brady PW, Varadarajan K, Peterson LE, et al. Prevalence and nature of adverse medical device events in hospitalized children. J Hosp Med. 2013;8(7):390-3. doi:10.1002/jhm.2058. https://psnet.ahrq.gov/issue/prevalence-an…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43678/psn-pdf
    April 22, 2015 - 'Connecting the dots': leveraging visual analytics to make sense of patient safety event reports. April 22, 2015 Ratwani RM, Fong A. 'Connecting the dots': leveraging visual analytics to make sense of patient safety event reports. J Am Med Inform Assoc. 2015;22(2):312-7. doi:10.1136/amiajnl-2014-002963. https://ps…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35802/psn-pdf
    January 02, 2017 - Reconciliation failures lead to medication errors. January 2, 2017 Santell JP. Reconciliation failures lead to medication errors. Jt Comm J Qual Patient Saf. 2006;32(4):225-9. https://psnet.ahrq.gov/issue/reconciliation-failures-lead-medication-errors Medication reconciliation represents an active effort of hospita…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34656/psn-pdf
    May 27, 2011 - A look into the nature and causes of human errors in the intensive care unit. May 27, 2011 Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995;23(2):294-300. https://psnet.ahrq.gov/issue/look-nature-and-causes-human-errors-intensive-…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46000/psn-pdf
    April 26, 2017 - Diagnostic error in the emergency department: follow up of patients with minor trauma in the outpatient clinic. April 26, 2017 Moonen P-J, Mercelina L, Boer W, et al. Diagnostic error in the Emergency Department: follow up of patients with minor trauma in the outpatient clinic. Scand J Trauma Resusc Emerg Med. 2017…

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