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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47219/psn-pdf
    July 25, 2018 - Preparing clinicians for transitioning patients across care settings and into the home through simulation. July 25, 2018 Molloy MA, Cary MP, Brennan-Cook J, et al. Preparing Clinicians for Transitioning Patients Across Care Settings and Into the Home Through Simulation. Home Healthc Now. 2018;36(4):225-231. doi:10…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849135/psn-pdf
    May 17, 2023 - Quality and Safety Considerations in Intensity Modulated Radiation Therapy: An ASTRO Safety White Paper Update. May 17, 2023 Moran JM, Bazan JG, Dawes SL, et al. Quality and Safety Considerations in Intensity Modulated Radiation Therapy: An ASTRO Safety White Paper Update. Pract Radiat Oncol. 2023;13(3):203-216. …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866648/psn-pdf
    September 04, 2024 - ACOG Committee Statement No. 10: Racial and Ethnic Inequities in Obstetrics and Gynecology. September 4, 2024 ACOG Committee Statement No. 10: Racial and Ethnic Inequities in Obstetrics and Gynecology. Obstet Gynecol. 2024;144(3):e62-e74. doi:10.1097/aog.0000000000005678. https://psnet.ahrq.gov/issue/acog-committe…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43038/psn-pdf
    March 05, 2014 - Missed it. March 5, 2014 Green MJ, Rieck R. Missed it. Ann Intern Med. 2013;158(5 Pt 1):357-61. doi:10.7326/0003-4819-158-5- 201303050-00013. https://psnet.ahrq.gov/issue/missed-it-0 This piece uses a graphic novel format to depict a story of a diagnostic error that resulted in a patient’s death. The attention-gr…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844783/psn-pdf
    September 04, 2019 - A lethal hidden curriculum—death of a medical student from opioid use disorder. September 4, 2019 Lucey CR, Jones L, Eastburn A. A Lethal Hidden Curriculum - Death of a Medical Student from Opioid Use Disorder. N Engl J Med. 2019;381(9):793-795. doi:10.1056/NEJMp1901537. https://psnet.ahrq.gov/issue/lethal-hidden-…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46926/psn-pdf
    March 07, 2018 - A comprehensive program to reduce rates of hospital- acquired pressure ulcers in a system of community hospitals. March 7, 2018 Englebright J, Westcott R, McManus K, et al. A Comprehensive Program to Reduce Rates of Hospital- Acquired Pressure Ulcers in a System of Community Hospitals. J Patient Saf. 2018;14(1):54…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44780/psn-pdf
    May 09, 2017 - Improving anesthesiologists' ability to speak up in the operating room: a randomized controlled experiment of a simulation-based intervention and a qualitative analysis of hurdles and enablers. May 9, 2017 Raemer DB, Kolbe M, Minehart RD, et al. Improving Anesthesiologists’ Ability to Speak Up in the Operating Ro…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47975/psn-pdf
    May 29, 2019 - Surgical Innovation, New Techniques and Technologies: A Guide to Good Practice. May 29, 2019 London, UK: Royal College of Surgeons of England; 2019. https://psnet.ahrq.gov/issue/surgical-innovation-new-techniques-and-technologies-guide-good-practice Introducing innovations in practice involves taking calculated ri…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43637/psn-pdf
    April 25, 2016 - Lost in translation? Addressing barriers in the application of industrial process improvement methodologies to health care. April 25, 2016 Gray D, Johnson KD, Watts B. Lost In Translation? Addressing Barriers in the Application of Industrial Process Improvement Methodologies to Health Care. Jt Comm J Qual Patient …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45670/psn-pdf
    November 16, 2016 - Not thinking clearly? Play a game, seriously! November 16, 2016 Mohan D, Schell J, Angus DC. Not Thinking Clearly? Play a Game, Seriously!. JAMA. 2016;316(18):1867- 1868. doi:10.1001/jama.2016.14174. https://psnet.ahrq.gov/issue/not-thinking-clearly-play-game-seriously Heuristics enable experts to build off their …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60600/psn-pdf
    June 17, 2020 - Reasons for drug administration problems and perceived needs for assistance of patients, family caregivers, and nurses: a qualitative study. June 17, 2020 Lampert A, Haefeli WE, Seidling HM. Reasons for drug administration problems and perceived needs for assistance of patients, family caregivers, and nurses: a qu…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34700/psn-pdf
    January 04, 2017 - Reducing adverse drug events: lessons from a breakthrough series collaborative. January 4, 2017 Leape L, Kabcenell AI, Gandhi TK, et al. Reducing adverse drug events: lessons from a breakthrough series collaborative. Jt Comm J Qual Improv. 2000;26(6):321-31. https://psnet.ahrq.gov/issue/reducing-adverse-drug-event…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866355/psn-pdf
    July 24, 2024 - Frequency and preventability of adverse drug events in the outpatient setting. July 24, 2024 Wasserman RL, Edrees HH, Amato MG, et al. Frequency and preventability of adverse drug events in the outpatient setting. BMJ Qual Saf. 2024;Epub Jul 9. doi:10.1136/bmjqs-2024-017098. https://psnet.ahrq.gov/issue/frequency-…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60621/psn-pdf
    June 24, 2020 - Design and implementation of the infection prevention program into risk management: managing high level disinfection and sterilization in the outpatient setting. June 24, 2020 Sweet W, Snyder D, Raymond M. Design and implementation of the infection prevention program into risk management: Managing high level disin…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50688/psn-pdf
    November 20, 2019 - Roles and role ambiguity in patient- and caregiver- performed outpatient parenteral antimicrobial therapy. November 20, 2019 Keller SC, Cosgrove SE, Arbaje AI, et al. Roles and Role Ambiguity in Patient- and Caregiver-Performed Outpatient Parenteral Antimicrobial Therapy. Jt Comm J Qual Patient Saf. 2019;45(11):763…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837510/psn-pdf
    June 22, 2022 - In situ simulation for adoption of new technology to improve sepsis care in rural emergency departments. June 22, 2022 Powell ES, Bond WF, Barker LT, et al. In situ simulation for adoption of new technology to improve sepsis care in rural emergency departments. J Patient Saf. 2022;18(4):302-309. doi:10.1097/pts.00…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48011/psn-pdf
    May 29, 2019 - Is it time for safeguards in the adoption of robotic surgery? May 29, 2019 Sheetz KH, Dimick JB. Is It Time for Safeguards in the Adoption of Robotic Surgery? JAMA. 2019;321(20):1971-1972. doi:10.1001/jama.2019.3736. https://psnet.ahrq.gov/issue/it-time-safeguards-adoption-robotic-surgery The FDA recently raised …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73462/psn-pdf
    July 07, 2021 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries. July 7, 2021 Abela G. Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries. J Tissue Viability. 2021;30(3):339-345. doi:10.1016/j.jtv.2021.04.00…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45815/psn-pdf
    January 25, 2017 - Handoffs: transitions of care for children in the emergency department. January 25, 2017 American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Emergency Medicine Committee, Emergency Nurses Association Pediatric Committee. Pediatrics. 2016;138:…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40563/psn-pdf
    September 09, 2011 - Shedding light on the dark side of doctor–patient interactions: verbal and nonverbal messages physicians communicate during error disclosures. September 9, 2011 Hannawa AF. Shedding light on the dark side of doctor-patient interactions: verbal and nonverbal messages physicians communicate during error disclosures.…