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psnet.ahrq.gov/node/854634/psn-pdf
January 01, 2024 - Elopement: evidence-based mitigation and management.
October 18, 2023
Marlett JE, Vacovsky BA, Krug EA, et al. Elopement: evidence?based mitigation and management.
Worldviews Evid Based Nurs. 2024;20(6):634-641. doi:10.1111/wvn.12683.
https://psnet.ahrq.gov/issue/elopement-evidence-based-mitigation-and-management
…
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psnet.ahrq.gov/node/35732/psn-pdf
April 06, 2016 - The London Declaration.
April 6, 2016
World Alliance for Patient Safety; World Health Organization; Patients for Patient Safety
https://psnet.ahrq.gov/issue/london-declaration
In this statement, Patients for Patient Safety pledge their commitment to representing and collaborating
with patients to reduce medical er…
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psnet.ahrq.gov/node/866281/psn-pdf
July 10, 2024 - Updating Eindhoven: clarifying the features of a patient
safety near miss.
July 10, 2024
Woodier N, Burnett C, Sampson P, et al. Updating Eindhoven: clarifying the features of a patient safety
near miss. J Patient Saf Risk Manag. 2024;29(4):195-201. doi:10.1177/25160435241247096.
https://psnet.ahrq.gov/issue/updat…
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psnet.ahrq.gov/node/836787/psn-pdf
December 01, 2021 - The second victim: a contested term?
December 1, 2021
Tumelty M-E. The second victim: a contested term? J Patient Saf. 2021;17(8):e1488-e1493.
doi:10.1097/pts.0000000000000558.
https://psnet.ahrq.gov/issue/second-victim-contested-term
There has been some controversy around the term ‘second victim.’ Based on qualit…
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psnet.ahrq.gov/node/72688/psn-pdf
October 06, 2022 - Request for proposals for clinical quality measures to
improve diagnosis.
October 6, 2022
Palo Alto CA; Gordon and Betty Moore Foundation: February 22, 2022.
https://psnet.ahrq.gov/issue/request-proposals-clinical-quality-measures-improve-diagnosis
A lack of consensus on measures for the effectiveness and ac…
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psnet.ahrq.gov/node/867046/psn-pdf
October 30, 2024 - The future of safety and quality in radiation oncology.
October 30, 2024
Talcott W, Covington E, Bazan J, et al. The future of safety and quality in radiation oncology. Semin Radiat
Oncol. 2024;34(4):433-440. doi:10.1016/j.semradonc.2024.07.008.
https://psnet.ahrq.gov/issue/future-safety-and-quality-radiation-oncol…
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psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
April 30, 2014 - SPOTLIGHT CASE
Diagnosing Diagnostic Mistakes
Citation Text:
McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google S…
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psnet.ahrq.gov/node/34612/psn-pdf
January 21, 2015 - Canadian Patient Safety Dictionary.
January 21, 2015
Royal College of Physicians and Surgeons of Canada
https://psnet.ahrq.gov/issue/canadian-patient-safety-dictionary
Developed by the Systems Issues Working Group of the National Steering Committee on Patient Safety,
the dictionary represents an effort to establis…
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psnet.ahrq.gov/node/846163/psn-pdf
March 15, 2023 - Using A.I. to detect breast cancer that doctors miss.
March 15, 2023
Satariano A, Metz C. New York Times. March 5, 2023.
https://psnet.ahrq.gov/issue/using-ai-detect-breast-cancer-doctors-miss
Artificial intelligence (AI) is an innovation that represents great promise for diagnostic accuracy and
timeliness im…
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psnet.ahrq.gov/node/47788/psn-pdf
March 06, 2019 - Medical device-related pressure ulcers: a systematic
review and meta-analysis.
March 6, 2019
Jackson D, Sarki AM, Betteridge R, et al. Medical device-related pressure ulcers: A systematic review and
meta-analysis. Int J Nurs Stud. 2019;92:109-120. doi:10.1016/j.ijnurstu.2019.02.006.
https://psnet.ahrq.gov/issue/me…
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psnet.ahrq.gov/node/841482/psn-pdf
December 14, 2022 - Errors in surgery: a case control study.
December 14, 2022
Marsh KM, Turrentine FE, Schenk WG, et al. Errors in surgery: a case control study. Ann Surg.
2022;276(5):e347-e352. doi:10.1097/sla.0000000000005664.
https://psnet.ahrq.gov/issue/errors-surgery-case-control-study
The perioperative period represents a vuln…
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psnet.ahrq.gov/node/845075/psn-pdf
February 22, 2023 - Artificial intelligence, patient safety, and achieving the
quintuple aim in anesthesiology.
February 22, 2023
Tan JM, Cannesson MP. APSF Newsletter. 2023;38(2):1,3–4,7.
https://psnet.ahrq.gov/issue/artificial-intelligence-patient-safety-and-achieving-quintuple-aim-anesthesiology
Technological advancement…
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psnet.ahrq.gov/node/50640/psn-pdf
November 06, 2019 - Cascades of care after incidental findings in a US national
survey of physicians.
November 6, 2019
Ganguli I, Simpkin AL, Lupo C, et al. Cascades of Care After Incidental Findings in a US National Survey of
Physicians. JAMA Netw Open. 2019;2(10):e1913325. doi:10.1001/jamanetworkopen.2019.13325.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/34123/psn-pdf
November 02, 2014 - Preventing Infections in the Hospital—What You As a
Patient Can Do.
November 2, 2014
National Patient Safety Foundation; NPSF
https://psnet.ahrq.gov/issue/preventing-infections-hospital-what-you-patient-can-do
Postoperative infections represent a common and often preventable event. This patient fact sheet outlines…
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psnet.ahrq.gov/node/50644/psn-pdf
November 06, 2019 - Hearing: Broken Promises: Assessing VA’s Systems for
Protecting Veterans from Clinical Harm.
November 6, 2019
US House of Representatives Committee on Veterans Affairs Subcommittee on Oversight and
Investigations. 116th Cong, 1st Sess (2019).
https://psnet.ahrq.gov/issue/hearing-broken-promises-assessing-vas-syste…
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psnet.ahrq.gov/node/851653/psn-pdf
July 26, 2023 - Content analysis of nurses' reflections on medication
errors in a regional hospital.
July 26, 2023
Issacs AN, RAYMOND A, KENT B. Content analysis of nurses’ reflections on medication errors in a
regional hospital. Contemp Nurse. 2023;59(3):202-213. doi:10.1080/10376178.2023.2220432.
https://psnet.ahrq.gov/issue/co…
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psnet.ahrq.gov/node/60535/psn-pdf
May 27, 2020 - Dramatic drop in cancer diagnoses amid COVID pandemic
is cause for concern, doctors say.
May 27, 2020
Abdelmalek M, Bruggeman L. ABC News. May 14, 2020.
https://psnet.ahrq.gov/issue/dramatic-drop-cancer-diagnoses-amid-covid-pandemic-cause-concern-
doctors-say
The COVID-19 pandemic has reduced patient use of prima…
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psnet.ahrq.gov/node/74209/psn-pdf
December 22, 2021 - Aligning patient safety and stewardship: a harm reduction
strategy for children.
December 22, 2021
Schefft M, Noda A, Godbout E. Aligning patient safety and stewardship: a harm reduction strategy for
children. Curr Treat Options Pediatr. 2021;7(3):138-151. doi:10.1007/s40746-021-00227-6.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/74128/psn-pdf
December 01, 2021 - Call to action: addressing pediatric fall safety in
ambulatory environments.
December 1, 2021
Benning S, Wolfe R, Banes M, et al. Call to action: addressing pediatric fall safety in ambulatory
environments. J Pediatr Nurs. 2021;61:372-377. doi:10.1016/j.pedn.2021.09.012.
https://psnet.ahrq.gov/issue/call-action-ad…
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psnet.ahrq.gov/node/74850/psn-pdf
February 16, 2022 - Medicare penalizes dozens of hospitals it also gives five
stars.
February 16, 2022
Rau J. Kaiser Health News. February 8, 2022.
https://psnet.ahrq.gov/issue/medicare-penalizes-dozens-hospitals-it-also-gives-five-stars
Rating systems face challenges to accurately represent the safety and quality of patient ca…