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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841139/psn-pdf
    December 14, 2022 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. December 14, 2022 Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. PSNet [internet]. 2022. https://psnet.ah…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73456/psn-pdf
    June 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia June 30, 2021 Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836862/psn-pdf
    April 06, 2022 - What are we missing? The quality of intraoperative handover before and after introduction of a checklist. April 6, 2022 Lane S, Gross M, Arzola C, et al. What are we missing? The quality of intraoperative handover before and after introduction of a checklist. Can J Anaesth. 2022;69(7):832-840. doi:10.1007/s12630-02…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47438/psn-pdf
    June 02, 2019 - Developing an intervention to reduce harm in hospitalized patients: patients and families in research. June 2, 2019 Schenk EC, Bryant RA, Van Son CR, et al. Developing an Intervention to Reduce Harm in Hospitalized Patients: Patients and Families in Research. J Nurs Care Qual. 2019;34(3):273-278. doi:10.1097/NCQ.0…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846147/psn-pdf
    March 15, 2023 - Automated capture of intraoperative adverse events using artificial intelligence: a systematic review and meta- analysis. March 15, 2023 Eppler MB, Sayegh AS, Maas M, et al. Automated capture of intraoperative adverse events using artificial intelligence: a systematic review and meta-analysis. J Clin Med. 2023;12(…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44695/psn-pdf
    June 07, 2016 - Enhancing surgical safety using digital multimedia technology. June 7, 2016 Dixon JL, Mukhopadhyay D, Hunt J, et al. Enhancing surgical safety using digital multimedia technology. Am J Surg. 2016;211(6):1095-8. doi:10.1016/j.amjsurg.2015.08.023. https://psnet.ahrq.gov/issue/enhancing-surgical-safety-using-digital-…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46241/psn-pdf
    January 30, 2018 - Interventions to improve oral chemotherapy safety and quality: a systematic review. January 30, 2018 Zerillo JA, Goldenberg BA, Kotecha RR, et al. Interventions to Improve Oral Chemotherapy Safety and Quality. JAMA Oncol. 2017;4(1):105-117. doi:10.1001/jamaoncol.2017.0625. https://psnet.ahrq.gov/issue/intervention…
  8. psnet.ahrq.gov/issue/preventing-medical-errors
    May 03, 2006 - Government Resource Preventing Medical Errors. Citation Text: Food and Drug Administration; FDA. Copy Citation Save Print Share Facebook Twitter Linkedin Copy URL September 10, 2008 Food and Drug Ad…
  9. psnet.ahrq.gov/issue/preventing-dosage-errors-diastat-acudial
    March 14, 2007 - Audiovisual Preventing dosage errors with Diastat AcuDial. Citation Text: Food and Drug Administration; FDA Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL January 17, 2007 …
  10. psnet.ahrq.gov/issue/teamstepps-health-care-risk-managers-improving-teamwork-and-communication
    March 27, 2019 - September 20, 2023 Videos of simulated after action reviews: a training resource to support
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73624/psn-pdf
    August 25, 2021 - System factors affecting patient safety in the OR: an analysis of safety threats and resiliency. August 25, 2021 Adams-McGavin RC, Jung JJ, van Dalen ASHM, et al. System factors affecting patient safety in the OR: an analysis of safety threats and resiliency. Ann Surg. 2021;274(1):114-119. doi:10.1097/sla.00000000…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72797/psn-pdf
    March 03, 2021 - Evaluating the impact of a pharmacist-led prescribing feedback intervention on prescribing errors in a hospital setting. March 3, 2021 Lloyd M, Watmough SD, O'Brien SV, et al. Evaluating the impact of a pharmacist-led prescribing feedback intervention on prescribing errors in a hospital setting. Res Social Adm Pha…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42839/psn-pdf
    January 09, 2014 - Teaching medical error disclosure to residents using patient-centered simulation training. January 9, 2014 Sukalich S, Elliott JO, Ruffner G. Teaching medical error disclosure to residents using patient-centered simulation training. Acad Med. 2014;89(1):136-43. doi:10.1097/ACM.0000000000000046. https://psnet.ahrq.…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44784/psn-pdf
    May 03, 2017 - WISH Patient Safety Forum May 3, 2017 World Innovation Summit for Health 2015. Doha, Qatar: Qatar Foundation; February 2015. https://psnet.ahrq.gov/issue/wish-patient-safety-forum The 2015 conference focused on persisting barriers to patient safety worldwide and recommended strategies to achieve lasting improvemen…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44190/psn-pdf
    June 03, 2015 - Minimizing medical mistakes: mother's mission to reduce hospital errors. June 3, 2015 Takahara D. KDVR. May 19, 2015. https://psnet.ahrq.gov/issue/minimizing-medical-mistakes-mothers-mission-reduce-hospital-errors Parents of children who experience harm in the course of medical care serve as advocates to drive saf…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43177/psn-pdf
    May 14, 2014 - Disclosing medical errors to patients: effects of nonverbal involvement. May 14, 2014 Hannawa AF. Disclosing medical errors to patients: effects of nonverbal involvement. Patient Educ Couns. 2014;94(3):310-313. doi:10.1016/j.pec.2013.11.007. https://psnet.ahrq.gov/issue/disclosing-medical-errors-patients-effects-n…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43249/psn-pdf
    June 18, 2014 - Automated and electronically assisted hand hygiene monitoring systems: a systematic review. June 18, 2014 Ward MA, Schweizer ML, Polgreen PM, et al. Automated and electronically assisted hand hygiene monitoring systems: a systematic review. Am J Infect Control. 2014;42(5):472-8. doi:10.1016/j.ajic.2014.01.002. ht…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39407/psn-pdf
    March 31, 2010 - What ring tone should be used for patient safety? Early results with a Blackberry-based telementoring safety solution. March 31, 2010 Parker A, Rubinfeld IS, Azuh O, et al. What ring tone should be used for patient safety? Early results with a Blackberry-based telementoring safety solution. Am J Surg. 2010;199(3):…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41534/psn-pdf
    July 25, 2012 - Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care. July 25, 2012 Hu Y-Y, Arriaga AF, Roth EM, et al. Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care. Ann Surg. 2012;256(2):203-10. doi:10.1097/SLA.0b013e…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38970/psn-pdf
    July 05, 2013 - Joint Commission Center for Transforming Healthcare. July 5, 2013 Joint Commission. https://psnet.ahrq.gov/issue/joint-commission-center-transforming-healthcare The Joint Commission has traditionally focused on accreditation of health care organizations and, through its Joint Commission Resources arm, on quality i…

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