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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44995/psn-pdf
    July 01, 2016 - The relationship between nursing experience and education and the occurrence of reported pediatric medication administration errors. July 1, 2016 Sears K, O'Brien-Pallas L, Stevens B, et al. The Relationship Between Nursing Experience and Education and the Occurrence of Reported Pediatric Medication Administration…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33932/psn-pdf
    May 27, 2011 - Preventable anesthesia mishaps: a study of human factors. May 27, 2011 Cooper JB, Newbower RS, Long CD, et al. Preventable anesthesia mishaps: a study of human factors. Anesthesiology. 1978;49(6):399-406. https://psnet.ahrq.gov/issue/preventable-anesthesia-mishaps-study-human-factors This study reports on the ret…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47892/psn-pdf
    March 27, 2019 - Addressing medicine's bias against patients who are overweight. March 27, 2019 Rubin R. Addressing Medicine's Bias Against Patients Who Are Overweight. JAMA. 2019;321(10):925-927. doi:10.1001/jama.2019.0048. https://psnet.ahrq.gov/issue/addressing-medicines-bias-against-patients-who-are-overweight Patients with o…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45903/psn-pdf
    June 21, 2017 - Association between state medical malpractice environment and postoperative outcomes in the United States. June 21, 2017 Minami CA, Sheils CR, Pavey E, et al. Association Between State Medical Malpractice Environment and Postoperative Outcomes in the United States. J Am Coll Surg. 2017;224(3):310-318.e2. doi:10.1…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44807/psn-pdf
    September 29, 2017 - Legal and policy interventions to improve patient safety. September 29, 2017 Kachalia A, Mello MM, Nallamothu BK, et al. Legal and Policy Interventions to Improve Patient Safety. Circulation. 2016;133(7):661-71. doi:10.1161/CIRCULATIONAHA.115.015880. https://psnet.ahrq.gov/issue/legal-and-policy-interventions-impro…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45358/psn-pdf
    August 24, 2016 - Healthcare staff wellbeing, burnout, and patient safety: a systematic review. August 24, 2016 Hall LH, Johnson J, Watt I, et al. Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review. PLoS One. 2016;11(7):e0159015. doi:10.1371/journal.pone.0159015. https://psnet.ahrq.gov/issue/healthcare-sta…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35048/psn-pdf
    June 22, 2009 - Reduction in warfarin adverse events requiring patient hospitalization after implementation of a pharmacist- managed anticoagulation service. June 22, 2009 Locke C, Ravnan SL, Patel R, et al. Reduction in warfarin adverse events requiring patient hospitalization after implementation of a pharmacist-managed anticoa…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34982/psn-pdf
    July 14, 2010 - Development of the ICU safety reporting system. July 14, 2010 Wu AW, Holzmueller CG, Lubomski LH, et al. J Patient Saf. 2005;1(1):23-32. https://psnet.ahrq.gov/issue/development-icu-safety-reporting-system This AHRQ-funded study describes the development of a Web-based, voluntary, and anonymous reporting system. T…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35340/psn-pdf
    July 10, 2008 - Posthospital medication discrepancies: prevalence and contributing factors. July 10, 2008 Coleman EA, Smith JD, Raha D, et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165(16):1842-1847. https://psnet.ahrq.gov/issue/posthospital-medication-discrepancies-prev…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73911/psn-pdf
    October 06, 2021 - Misdiagnosis of acute myocardial infarction: a systematic review of the literature. October 6, 2021 Kwok CS, Bennett S, Azam Z, et al. Misdiagnosis of acute myocardial infarction: a systematic review of the literature. Crit Pathw Cardiol. 2021;20(3):155-162. doi:10.1097/hpc.0000000000000256. https://psnet.ahrq.gov…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40942/psn-pdf
    November 23, 2011 - Vital signs: overdoses of prescription opioid pain relievers- United States, 1999-2008. November 23, 2011 Prevention C for DC and. Vital signs: overdoses of prescription opioid pain relievers---United States, 1999-- 2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-92. https://psnet.ahrq.gov/issue/vital-signs-over…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35127/psn-pdf
    February 24, 2011 - Beyond the medical record: other modes of error acknowledgment. February 24, 2011 Rosenthal M, Cornett PL, Sutcliffe K, et al. Beyond the medical record: other modes of error acknowledgment. J Gen Intern Med. 2005;20(5):404-9. https://psnet.ahrq.gov/issue/beyond-medical-record-other-modes-error-acknowledgment Thi…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851199/psn-pdf
    July 05, 2023 - Understanding the root cause analysis process to increase safety event reporting. July 5, 2023 Dudley KA. Understanding the root cause analysis process to increase safety event reporting. AORN J. 2023;117(6):399-402. doi:10.1002/aorn.13935. https://psnet.ahrq.gov/issue/understanding-root-cause-analysis-process-inc…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47075/psn-pdf
    November 21, 2018 - Integrating systemic accident analysis into patient safety incident investigation practices. November 21, 2018 Canham A, Jun GT, Waterson P, et al. Integrating systemic accident analysis into patient safety incident investigation practices. Appl Ergon. 2018;72:1-9. doi:10.1016/j.apergo.2018.04.012. https://psnet.a…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60669/psn-pdf
    July 08, 2020 - Participation in a system-thinking simulation experience changes adverse event reporting. July 8, 2020 Sanko JS, Mckay M. Participation in a system-thinking simulation experience changes adverse event reporting. Simul Healthc. 2020;15(3):167-171. doi:10.1097/sih.0000000000000473. https://psnet.ahrq.gov/issue/parti…

  16. Valdez Podcast Transcript (pdf file)

    digital.ahrq.gov/sites/default/files/docs/page/valdez-podcast-transcript.pdf
    July 21, 2014 - Valdez Podcast Transcript Podcast 4   Designing Culturally Informed Consumer Health IT (Dr. Rupa Valdez)    Narrator: Welcome to Health IT Spotlight from the Agency for Healthcare Research and Quality.  Patients are increasingly encouraged to use health IT applications to manage their own health  care. These applicat…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45799/psn-pdf
    May 09, 2017 - Assessing frequency and risk of weight entry errors in pediatrics. May 9, 2017 Hagedorn PA, Kirkendall E, Kouril M, et al. Assessing Frequency and Risk of Weight Entry Errors in Pediatrics. JAMA Pediatr. 2017;171(4):392-393. doi:10.1001/jamapediatrics.2016.3865. https://psnet.ahrq.gov/issue/assessing-frequency-and…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39840/psn-pdf
    September 15, 2010 - Wrong-site craniotomy: analysis of 35 cases and systems for prevention. September 15, 2010 Cohen FL, Mendelsohn D, Bernstein M. Wrong-site craniotomy: analysis of 35 cases and systems for prevention. J Neurosurg. 2010;113(3):461-73. doi:10.3171/2009.10.JNS091282. https://psnet.ahrq.gov/issue/wrong-site-craniotomy-…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43129/psn-pdf
    July 23, 2014 - Use of a daily goals checklist for morning ICU rounds: a mixed-methods study. July 23, 2014 Centofanti JE, Duan EH, Hoad NC, et al. Use of a daily goals checklist for morning ICU rounds: a mixed- methods study. Crit Care Med. 2014;42(8):1797-803. doi:10.1097/CCM.0000000000000331. https://psnet.ahrq.gov/issue/use-d…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44524/psn-pdf
    March 16, 2016 - Application of a human factors classification framework for patient safety to identify precursor and contributing factors to adverse clinical incidents in hospital. March 16, 2016 Mitchell RJ, Williamson A, Molesworth B. Application of a human factors classification framework for patient safety to identify precurs…
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