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221. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60319/psn-pdf
     May 13, 2020 - Predictors of nursing home nurses' willingness to report medication near-misses. May 13, 2020 Farag A, Vogelsmeier A, Knox K, et al. Predictors of nursing home nurses' willingness to report medication near-misses. J Gerontol Nurs. 2020;46(4):21-30. doi:10.3928/00989134-20200303-03. https://psnet.ahrq.gov/issue/pre…

222. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42036/psn-pdf
     March 18, 2013 - Changes in adverse event rates in hospitals over time: a longitudinal retrospective patient record review study. March 18, 2013 Baines RJ, Langelaan M, de Bruijne M, et al. Changes in adverse event rates in hospitals over time: a longitudinal retrospective patient record review study. BMJ Qual Saf. 2013;22(4):290-8…

223. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43995/psn-pdf
     August 02, 2015 - Patient access to electronic health records during hospitalization. August 2, 2015 Pell JM, Mancuso M, Limon S, et al. Patient access to electronic health records during hospitalization. JAMA Intern Med. 2015;175(5):856-858. doi:10.1001/jamainternmed.2015.121. https://psnet.ahrq.gov/issue/patient-access-electronic…

224. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38416/psn-pdf
     February 18, 2009 - Preanalytical errors in primary healthcare: a questionnaire study of information search procedures, test request management and test tube labelling. February 18, 2009 Söderberg J, Brulin C, Grankvist K, et al. Preanalytical errors in primary healthcare: a questionnaire study of information search procedures, test …

225. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34866/psn-pdf
     February 03, 2011 - Error reporting and disclosure systems: views from hospital leaders. February 3, 2011 Weissman JS, Annas CL, Epstein AM, et al. Error reporting and disclosure systems: views from hospital leaders. JAMA. 2005;293(11):1359-66. https://psnet.ahrq.gov/issue/error-reporting-and-disclosure-systems-views-hospital-leaders…

226. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40844/psn-pdf
     January 04, 2012 - Intensive care unit readmissions in U.S. hospitals: patient characteristics, risk factors, and outcomes. January 4, 2012 Kramer AA, Higgins TL, Zimmerman JE. Intensive care unit readmissions in U.S. hospitals: patient characteristics, risk factors, and outcomes. Crit Care Med. 2012;40(1):3-10. doi:10.1097/CCM.0b01…

227. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-433
     March 27, 2024 - March 27, 2024 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, reports,…

228. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867379/psn-pdf
     January 01, 2025 - Implementation of electronic triggers to identify diagnostic errors in emergency departments. December 18, 2024 Vaghani V, Gupta A, Mir U, et al. Implementation of electronic triggers to identify diagnostic errors in emergency departments. JAMA Intern Med. 2025;185(2):143-151. doi:10.1001/jamainternmed.2024.6214. …

229. Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics. | PSNet
     psnet.ahrq.gov/issue/missed-diagnoses-acute-myocardial-infarction-emergency-department-variation-patient-and
     April 08, 2018 - Study Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics. Citation Text: Moy E, Barrett M, Coffey R, et al. Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and fa…

230. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44431/psn-pdf
     October 21, 2015 - Use of a human factors classification framework to identify causal factors for medication and medical device- related adverse clinical incidents. October 21, 2015 Mitchell RJ, Williamson A, Molesworth B. Use of a human factors classification framework to identify causal factors for medication and medical device-re…

231. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43568/psn-pdf
     April 25, 2016 - Medication safety in the operating room: a survey of preparation methods and drug concentration consistencies in children's hospitals in the United States. April 25, 2016 Shaw RE, Litman RS. Medication Safety in the Operating Room: A Survey of Preparation Methods and Drug Concentration Consistencies in Children's …

232. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34061/psn-pdf
     January 04, 2017 - Patient Safety Leadership WalkRounds. January 4, 2017 Frankel A, Graydon-Baker E, Neppl C, et al. Patient Safety Leadership WalkRounds. Jt Comm J Qual Saf. 2003;29(1). doi:10.1016/s1549-3741(03)29003-1. https://psnet.ahrq.gov/issue/patient-safety-leadership-walkrounds This study shares the concept of an interventi…

233. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33591/psn-pdf
     September 07, 2019 - Triggers and Trigger Tools September 7, 2019 Triggers and Trigger Tools. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/triggers-and-trigger-tools Background and definition Health care organizations use a variety of strategies to detect safety hazards in order to prevent harm. These methods are often refer…

234. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60278/psn-pdf
     April 29, 2020 - Assessing patient safety in a pediatric telemedicine setting: a multi-methods study. April 29, 2020 Haimi M, Brammli-Greenberg S, Baron-Epel O, et al. Assessing patient safety in a pediatric telemedicine setting: a multi-methods study. BMC Med Inform Decis Mak. 2020;20(1). doi:10.1186/s12911-020-1074-7. https://ps…

235. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60933/psn-pdf
     September 23, 2020 - Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. September 23, 2020 Self WH, Tenforde MW, Stubblefield WB, et al. Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network - 1…

236. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838251/psn-pdf
     October 05, 2022 - Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery. October 5, 2022 Uramatsu M, Maeda H, Mishima S, et al. Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery. J Cardiothorac Surg.…

237. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33861/psn-pdf
     July 01, 2018 - But every day, blood samples are switched between two patients.

238. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46013/psn-pdf
     January 01, 2018 - The dichotomy of the application of a systems approach in UK healthcare the challenges and priorities for implementation. December 19, 2017 Pickup L, Lang A, Atkinson S, et al. The dichotomy of the application of a systems approach in UK healthcare the challenges and priorities for implementation. Ergonomics. 2018…

239. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47181/psn-pdf
     August 22, 2018 - Critical role of the surgeon–anesthesiologist relationship for patient safety. August 22, 2018 Cooper JB. Critical Role of the Surgeon-Anesthesiologist Relationship for Patient Safety. Anesthesiology. 2018;129(3):402-405. doi:10.1097/ALN.0000000000002324. https://psnet.ahrq.gov/issue/critical-role-surgeon-anesthes…

240. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44936/psn-pdf
     May 09, 2017 - Potential benefit of electronic pharmacy claims data to prevent medication history errors and resultant inpatient order errors. May 9, 2017 Pevnick JM, Palmer KA, Shane R, et al. Potential benefit of electronic pharmacy claims data to prevent medication history errors and resultant inpatient order errors. J Am Med…