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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43022/psn-pdf
    May 29, 2014 - Using simulation to improve root cause analysis of adverse surgical outcomes. May 29, 2014 Slakey DP, Simms ER, Rennie K, et al. Using simulation to improve root cause analysis of adverse surgical outcomes. Int J Qual Health Care. 2014;26(2):144-50. doi:10.1093/intqhc/mzu011. https://psnet.ahrq.gov/issue/using-sim…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36917/psn-pdf
    September 01, 2011 - Analysis of deaths related to anesthesia in the period 1996-2004 from closed claims registered by the Danish Patient Insurance Association. September 1, 2011 Hove LD, Steinmetz J, Christoffersen JK, et al. Analysis of deaths related to anesthesia in the period 1996- 2004 from closed claims registered by the Danish…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74108/psn-pdf
    January 01, 2022 - 'It depends': The complexity of allowing residents to fail from the perspective of clinical supervisors. November 24, 2021 Klasen JM, Teunissen PW, Driessen EW, et al. ‘It depends’: the complexity of allowing residents to fail from the perspective of clinical supervisors. Med Teach. 2022;44(2):196-205. doi:10.1080…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42860/psn-pdf
    March 20, 2014 - Eight critical factors in creating and implementing a successful simulation program. March 20, 2014 Lazzara EH, Benishek LE, Dietz AS, et al. Eight critical factors in creating and implementing a successful simulation program. Jt Comm J Qual Patient Saf. 2014;40(1):21-29. https://psnet.ahrq.gov/issue/eight-critica…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43515/psn-pdf
    July 03, 2016 - Targeting improvements in patient safety at a large academic center: an institutional handoff curriculum for graduate medical education. July 3, 2016 Allen S, Caton C, Cluver J, et al. Targeting improvements in patient safety at a large academic center: an institutional handoff curriculum for graduate medical educ…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34750/psn-pdf
    May 21, 2019 - The Basics of FMEA. 2nd ed. May 21, 2019 McDermott RE, Mikulak RJ, Beauregard MR. New York, NY: CRC Press; 2009. ISBN: 9781563273773. https://psnet.ahrq.gov/issue/basics-fmea-2nd-edition The authors provide a handbook that serves as the core tool for understanding and implementing the failure mode and effect analy…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43019/psn-pdf
    March 05, 2014 - Augmenting health care failure modes and effects analysis with simulation. March 5, 2014 Nielsen DS, Dieckmann P, Mohr M, et al. Augmenting health care failure modes and effects analysis with simulation. Simul Healthc. 2014;9(1):48-55. doi:10.1097/SIH.0b013e3182a3defd. https://psnet.ahrq.gov/issue/augmenting-healt…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44469/psn-pdf
    September 16, 2015 - Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin. September 16, 2015 Washington, DC: VA Office of Inspector General. August 6, 2015. Report No. 15-02131-471. https://psnet.ahrq.gov/issue/unexpected-death-patient-during-treatment-multiple-medication…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46963/psn-pdf
    April 18, 2018 - A Just Culture Guide. April 18, 2018 NHS Improvement. London, UK: National Health Service; March 15, 2018. https://psnet.ahrq.gov/issue/just-culture-guide Although focusing on system failure has been highlighted as key to improving patient safety, individual behaviors must also be recognized as contributors to ris…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41802/psn-pdf
    October 31, 2012 - Relationship between high-fidelity simulation and patient safety in prelicensure nursing education: a comprehensive review. October 31, 2012 Blum CA, Parcells DA. Relationship between high-fidelity simulation and patient safety in prelicensure nursing education: a comprehensive review. J Nurs Educ. 2012;51(8):429-…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39603/psn-pdf
    February 16, 2011 - The Schwartz Center Rounds: evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, and provider support. February 16, 2011 Lown BA, Manning CF. The Schwartz Center Rounds: evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, …
  12. www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/index.html
    September 01, 2021 - Long-term Care Facilities Resources for long-term care facilities Improving Patient Safety in Long-Term Care Facilities Detecting and promptly reporting changes in a nursing home resident's condition are critical for ensuring the resident's well-being and safety. Such changes may represent a patient s…
  13. digital.ahrq.gov/organization/michigan-state-university
    January 01, 2023 - Michigan State University Telehealth Post-Pandemic: A Roadmap for the Coming Decade Description This conference grant will support a multidisciplinary Think Tank to develop and disseminate telehealth best practices, training curriculum recommendations, and policy recommendatio…
  14. digital.ahrq.gov/location/usa-mi-east-lansing
    January 01, 2023 - USA, MI, East Lansing Telehealth Post-Pandemic: A Roadmap for the Coming Decade Description This conference grant will support a multidisciplinary Think Tank to develop and disseminate telehealth best practices, training curriculum recommendations, and policy recommendations t…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73496/psn-pdf
    July 14, 2021 - Racism in pain medicine: we can and should do more. July 14, 2021 Strand NH, Mariano ER, Goree JH, et al. Racism in pain medicine: we can and should do more. Mayo Clin Proc. 2021;96(6):1394-1400. doi:10.1016/j.mayocp.2021.02.030. https://psnet.ahrq.gov/issue/racism-pain-medicine-we-can-and-should-do-more Systemic …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850938/psn-pdf
    June 21, 2023 - AI in medicine needs to be carefully deployed to counter bias – and not entrench it. June 21, 2023 Levi R, Gorenstein D. Health Shots. National Public Radio. June 6, 2023. https://psnet.ahrq.gov/issue/ai-medicine-needs-be-carefully-deployed-counter-bias-and-not-entrench-it Systemic biases are present in data …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72796/psn-pdf
    March 03, 2021 - Patient safety. Factors for and perceived consequences of nursing errors by nursing staff in home care services. March 3, 2021 Jachan DE, Müller?Werdan U, Lahmann NA. Patient safety. Factors for and perceived consequences of nursing errors by nursing staff in home care services. Nurs Open. 2021;8(2):755-765. doi:1…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44782/psn-pdf
    January 13, 2016 - The Swiss cheese model of adverse event occurrence—closing the holes. January 13, 2016 Stein JE, Heiss K. The Swiss cheese model of adverse event occurrence--Closing the holes. Semin Pediatr Surg. 2015;24(6):278-82. doi:10.1053/j.sempedsurg.2015.08.003. https://psnet.ahrq.gov/issue/swiss-cheese-model-adverse-event…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34801/psn-pdf
    February 10, 2011 - Medication prescribing errors in a teaching hospital. February 10, 2011 Lesar TS, Briceland LL, Delcoure K, et al. Medication prescribing errors in a teaching hospital. JAMA. 1990;263(17):2329-34. https://psnet.ahrq.gov/issue/medication-prescribing-errors-teaching-hospital This study analyzed nearly 290,000 medica…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45987/psn-pdf
    April 26, 2017 - Using simulation to prepare nursing staff for the move to a new building. April 26, 2017 Knippa S, Senecal P-A. Using Simulation to Prepare Nursing Staff for the Move to a New Building. J Nurses Prof Dev. 2017;33(2):E1-E5. doi:10.1097/NND.0000000000000329. https://psnet.ahrq.gov/issue/using-simulation-prepare-nurs…