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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43666/psn-pdf
    March 14, 2016 - Interdisciplinary Quality Improvement Conference: using a revised morbidity and mortality format to focus on systems-based patient safety issues in a VA hospital: design and outcomes. March 14, 2016 Gerstein WH, Ledford J, Cooper J, et al. Interdisciplinary Quality Improvement Conference: using a revised morbidit…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46993/psn-pdf
    July 18, 2018 - The nature, magnitude, and reporting compliance of device-related events for intravenous patient-controlled analgesia in the FDA Manufacturer and User Facility Device Experience (MAUDE) database. July 18, 2018 Lawal OD, Mohanty M, Elder H, et al. The nature, magnitude, and reporting compliance of device-related e…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867234/psn-pdf
    December 04, 2024 - Survey results reveal tubing misconnections are common and underreported—Parts I and II. December 4, 2024 Survey results reveal tubing misconnections are common and underreported—Parts I and II. ISMP Medication Safety Alert! Acute Care. October 31, 2024;29(22 & 23):1-5;1-4. https://psnet.ahrq.gov/issue/survey-resu…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838131/psn-pdf
    January 01, 2023 - What I wish I’d known: how experienced physician managers diagnose, treat and prevent disruptive behaviour. September 21, 2022 Goodwin C, Haas S, Berry WR. What I wish I’d known: how experienced physician managers diagnose, treat and prevent disruptive behaviour. BMJ Lead. 2023;7(2):128-132. doi:10.1136/leader-202…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46346/psn-pdf
    October 29, 2017 - Root cause analysis of ICU adverse events in the Veterans Health Administration. October 29, 2017 Corwin GS, Mills PD, Shanawani H, et al. Root Cause Analysis of ICU Adverse Events in the Veterans Health Administration. Jt Comm J Qual Patient Saf. 2017;43(11):580-590. doi:10.1016/j.jcjq.2017.04.009. https://psnet.…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37984/psn-pdf
    August 13, 2008 - Planning and implementing a systems-based patient safety curriculum in medical education. August 13, 2008 Thompson DA, Cowan J, Holzmueller CG, et al. Planning and implementing a systems-based patient safety curriculum in medical education. Am J Med Qual. 2008;23(4):271-8. doi:10.1177/1062860608317763. https://ps…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866107/psn-pdf
    June 12, 2024 - Hospital inpatient nutrition service errors and patient safety interventions: a scoping review. June 12, 2024 Austria D, McConnell C, Pope C. Hospital inpatient nutrition service errors and patient safety interventions: a scoping review. J Patient Saf. 2024;20(4):272-278. doi:10.1097/pts.0000000000001223. https://…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854251/psn-pdf
    October 04, 2023 - A scoping review exploring the confidence of healthcare professionals in assessing all skin tones. October 4, 2023 Harrison J. A scoping review exploring the confidence of healthcare professionals in assessing all skin tones. Br Paramed J. 2023;8(2):18-28. doi:10.29045/14784726.2023.9.8.2.18. https://psnet.ahrq.go…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37903/psn-pdf
    May 09, 2013 - Safe Surgery. May 9, 2013 World Health Organization. https://psnet.ahrq.gov/issue/safe-surgery-saves-lives-second-global-patient-safety-challenge This initiative provides a surgical safety checklist and related educational and training materials building on the Second Global Patient Safety Challenge vision to enco…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/764405/psn-pdf
    March 02, 2022 - Evaluation of communication and safety behaviors during hospital-wide code response simulation. March 2, 2022 Ren DM, Abrams A, Banigan M, et al. Evaluation of communication and safety behaviors during hospital- wide code response simulation. Simul Healthc. 2022;17(1):e45-e50. doi:10.1097/sih.0000000000000575. htt…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40355/psn-pdf
    July 09, 2012 - The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives. July 9, 2012 Maxfield D, Grenny J, Lavandero R, et al. Provo, UT: VitalSmarts; 2011. https://psnet.ahrq.gov/issue/silent-treatment-why-safety-tools-and-checklists-arent-enough-save-lives Silence Kills was a 2005 report that highligh…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36644/psn-pdf
    July 10, 2008 - Reporting and disclosing medical errors: pediatricians' attitudes and behaviors. July 10, 2008 Garbutt J, Brownstein DR, Klein EJ, et al. Reporting and disclosing medical errors: pediatricians' attitudes and behaviors. Arch Pediatr Adolesc Med. 2007;161(2):179-85. https://psnet.ahrq.gov/issue/reporting-and-disclos…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47323/psn-pdf
    September 26, 2018 - About politeness, face, and feedback: exploring resident and faculty perceptions of how institutional feedback culture influences feedback practices. September 26, 2018 Ramani S, Könings KD, Mann K, et al. About Politeness, Face, and Feedback: Exploring Resident and Faculty Perceptions of How Institutional Feedbac…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45594/psn-pdf
    December 19, 2017 - Teaching quality improvement and patient safety in residency education: strategies for meaningful resident quality and safety initiatives. December 19, 2017 Morrison RJ, Bowe SN, Brenner MJ. Teaching Quality Improvement and Patient Safety in Residency Education: Strategies for Meaningful Resident Quality and Safet…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60873/psn-pdf
    September 02, 2020 - What has been the impact of Covid-19 on safety culture? A case study from a large metropolitan healthcare trust. September 2, 2020 Denning M, Goh ET, Scott A, et al. What has been the impact of Covid-19 on safety culture? A case study from a large metropolitan healthcare trust. Int J Environ Res Public Health. 2020…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/862154/psn-pdf
    June 18, 2020 - Listening to women: recommendations from women of color to improve experiences in pregnancy and birth care. June 18, 2020 Altman MR, McLemore MR, Oseguera T, et al. Listening to women: recommendations from women of color to improve experiences in pregnancy and birth care. J Midwifery Womens Health. 2020;65(4):466-4…
  17. psnet.ahrq.gov/sites/default/files/2021-09/Battle%20buddies%20tip%20sheet%20(1).pdf
    January 01, 2021 - I have a Battle Buddy – Now What? Battle Buddies are not just for battle.  It’s critical to start connecting with your Battle Buddy now - before things get really stressful.  It’s like training prior to a marathon.  Brief conversations now will strengthen your individual and team resilience and ensure o…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836773/psn-pdf
    March 23, 2022 - Association between operative autonomy of surgical residents and patient outcomes. March 23, 2022 Oliver JB, Kunac A, McFarlane JL, et al. Association between operative autonomy of surgical residents and patient outcomes. JAMA Surg. 2022;157(3):211-219. doi:10.1001/jamasurg.2021.6444. https://psnet.ahrq.gov/issue/…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73666/psn-pdf
    September 01, 2021 - Implementation of participatory organizational change in long term care to improve safety. September 1, 2021 Van Eerd D, D'Elia T, Ferron EM, et al. Implementation of participatory organizational change in long term care to improve safety. J Safety Res. 2021;78:9-18. doi:10.1016/j.jsr.2021.05.002. https://psnet.ah…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837148/psn-pdf
    May 18, 2022 - Assessing quality of older persons' emergency transitions between long-term and acute care settings: a proof-of-concept study. May 18, 2022 Tate K, McLane P, Reid C, et al. Assessing quality of older persons’ emergency transitions between long- term and acute care settings: a proof-of-concept study. BMJ Open Qual.…