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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35314/psn-pdf
    August 31, 2005 - The health factory. August 31, 2005 Spear SJ. https://psnet.ahrq.gov/issue/health-factory In this editorial, the author suggests that health care organizations approach error the way other industries do, by constantly evaluating and solving problems, rather than working around them. https://psnet.ahrq.gov/issue/h…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33755/psn-pdf
    September 01, 2013 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety September 1, 2013 Singer SJ. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/what-weve-learned-ab…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33910/psn-pdf
    May 01, 2016 - Quick Tips—When Getting A Prescription. May 1, 2016 Agency for Healthcare Research and Quality; AHRQ. https://psnet.ahrq.gov/issue/quick-tips-when-getting-prescription This Web site suggests questions that all patients should ask a physician, nurse, and/or pharmacist when they receive a medication prescription. h…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38247/psn-pdf
    June 27, 2018 - Debriefing for patient safety. June 27, 2018 Turner SH, Kurtz WD. Patient Saf Qual Healthc. November/December 2008:5:42-44,46. https://psnet.ahrq.gov/issue/debriefing-patient-safety This article provides guidelines for effective clinical debriefings and suggests how to position these conversations as learning oppo…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36534/psn-pdf
    March 09, 2009 - Standardizing hand-off processes. March 9, 2009 Gregory BSC. Standardizing hand-off processes. AORN J. 2006;84(6):1059-61. https://psnet.ahrq.gov/issue/standardizing-hand-processes The author suggests ways to improve hand-off communications and provides an assessment form to assist staff in detecting weaknesses in…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40299/psn-pdf
    April 16, 2018 - Medication errors in the emergency department: need for pharmacy involvement? April 16, 2018 https://psnet.ahrq.gov/issue/medication-errors-emergency-department-need-pharmacy-involvement This piece reports on the prevalence of medication errors in the emergency department and suggests expanding pharmacy involvemen…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40525/psn-pdf
    June 15, 2011 - The normalization of deviance: what are the perioperative risks? June 15, 2011 McNamara SA. The normalization of deviance: what are the perioperative risks? AORN J. 2011;93(6):796- 801. doi:10.1016/j.aorn.2011.02.009. https://psnet.ahrq.gov/issue/normalization-deviance-what-are-perioperative-risks This commentary…
  8. psnet.ahrq.gov/issue/selected-medication-safety-risks-manage-2016-might-otherwise-fall-radar-screen-part-1-and
    March 09, 2016 - Newspaper/Magazine Article Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2. Citation Text: Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2. ISMP Medicat…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36599/psn-pdf
    August 09, 2011 - Why Current Breast Pathology Practices Must Be Evaluated. August 9, 2011 Dallas, TX: Susan G Komen Breast Cancer Foundation; 2006. https://psnet.ahrq.gov/issue/why-current-breast-pathology-practices-must-be-evaluated This report illustrates weaknesses in current pathology practice of breast cancer diagnosis and su…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40626/psn-pdf
    July 02, 2014 - Time to sign off on signout. July 2, 2014 Stein DM, Stetson PD. Commentary: time to sign off on signout. Acad Med. 2011;86(7):804-6. doi:10.1097/ACM.0b013e31821d8409. https://psnet.ahrq.gov/issue/time-sign-signout This commentary suggests standardized sign-outs can improve communication and handoffs. https://psne…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37354/psn-pdf
    November 21, 2007 - Fires during surgeries a bigger risk than thought. November 21, 2007 Kowalczyk L. Boston Globe. November 7, 2007 https://psnet.ahrq.gov/issue/fires-during-surgeries-bigger-risk-thought This article reports data suggesting that the number of surgical fires that occur annually may be higher than health care official…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35487/psn-pdf
    September 12, 2016 - Safety improvements urged for MRI facilities. September 12, 2016 Mitka M. Safety improvements urged for MRI facilities. JAMA. 2005;294(17):2145-8. https://psnet.ahrq.gov/issue/safety-improvements-urged-mri-facilities This news story from  JAMA summarizes a teleconference on magnetic resonance imaging safety and sh…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36546/psn-pdf
    January 10, 2011 - A systems approach to patient-centered care. January 10, 2011 Bergeson SC, Dean JD. A systems approach to patient-centered care. JAMA. 2006;296(23):2848-51. https://psnet.ahrq.gov/issue/systems-approach-patient-centered-care The authors suggest system-level changes to help health care professionals ensure that they…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36171/psn-pdf
    September 29, 2010 - Quality and safety in the intensive care unit. September 29, 2010 Stockwell DC, Slonim A. Quality and safety in the intensive care unit. J Intensive Care Med. 2006;21(4):199-210. https://psnet.ahrq.gov/issue/quality-and-safety-intensive-care-unit The authors provide background on patient safety in intensive care u…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40935/psn-pdf
    September 02, 2016 - A Review of FDA’s Approach to Medical Product Shortages. September 2, 2016 Silver Spring, MD: US Food and Drug Administration; October 31, 2011. https://psnet.ahrq.gov/issue/review-fdas-approach-medical-product-shortages This report outlines the complex nature of drug shortages and suggests strategies to augment t…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35232/psn-pdf
    December 09, 2008 - Patient safety: is it just another bandwagon? December 9, 2008 Storch JL. Patient safety: is it just another bandwagon? Nurs Leadersh (Tor Ont). 2005;18(2):39-55. https://psnet.ahrq.gov/issue/patient-safety-it-just-another-bandwagon The author advocates critical assessment of the patient safety movement and suggest…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35534/psn-pdf
    April 25, 2018 - Mail service and community pharmacies must work in tandem. April 25, 2018 ISMP Safe Medication Alert! Acute care edition. November 17, 2005. https://psnet.ahrq.gov/issue/mail-service-and-community-pharmacies-must-work-tandem This article discusses how community pharmacies are contributing to patient safety and sug…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40611/psn-pdf
    July 20, 2011 - The normalization of deviance: a threat to patient safety. July 20, 2011 Odom-Forren J. The normalization of deviance: a threat to patient safety. J Perianesth Nurs. 2011;26(3):216-9. doi:10.1016/j.jopan.2011.05.002. https://psnet.ahrq.gov/issue/normalization-deviance-threat-patient-safety This commentary describe…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38440/psn-pdf
    January 31, 2011 - Transformation of health care at the front line. January 31, 2011 Conway PH, Clancy CM. Transformation of health care at the front line. JAMA. 2009;301(7):763-5. doi:10.1001/jama.2009.103. https://psnet.ahrq.gov/issue/transformation-health-care-front-line This commentary emphasizes five key drivers to improve heal…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36169/psn-pdf
    August 09, 2006 - Disruptive clinician behavior: a persistent threat to patient safety. August 9, 2006 Porto G; Lauve R. Patient Safety Quality Healthcare. July / August 2006. https://psnet.ahrq.gov/issue/disruptive-clinician-behavior-persistent-threat-patient-safety The authors describe disruptive clinician behavior, contributing …

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