AHRQ Patient Safety Network http://psnet.ahrq.gov/ A continuously updated, annotated, and carefully selected collection of patient safety news, literature, tools, and resources. en-us AHRQ Patient Safety Network 100% 100% http://psnet.ahrq.gov/ http://psnet.ahrq.gov/mailimg/mast_psnetmail.gif Partnerships in Implementing Patient Safety II (R18). http://psnet.ahrq.gov/resource.aspx?resourceID=17078&rss=yes Rockville, MD: Agency for Healthcare Research and Quality. PAR-10-022. From a blame culture to a just culture in health care. http://psnet.ahrq.gov/resource.aspx?resourceID=17079&rss=yes Khatri N, Brown GD, Hicks LL. Health Care Manage Rev. 2009;34:312-322. Health literacy and quality: focus on chronic illness care and patient safety. http://psnet.ahrq.gov/resource.aspx?resourceID=17081&rss=yes Rothman RL, Yin HS, Mulvaney S, Co JPT, Homer C, Lannon C. Pediatrics. 2009;124(suppl 3):S315-S326. How long does it take to train a surgeon? http://psnet.ahrq.gov/resource.aspx?resourceID=17080&rss=yes Purcell Jackson G, Tarpley JL. BMJ. 2009;339:b4260. Interventions to improve team effectiveness: a systematic review. http://psnet.ahrq.gov/resource.aspx?resourceID=17066&rss=yes Buljac-Samardzic M, Dekker-van Doorn CM, van Wijngaarden JDH, van Wijk KP. Health Policy. 2009 Oct 24; [Epub ahead of print]. Action research, simulation, team communication, and bringing the tacit into voice. Society for Simulation in Healthcare. http://psnet.ahrq.gov/resource.aspx?resourceID=17074&rss=yes Forsythe L. Simul Healthc. 2009;4:143-148. Diagnostic error in medicine: analysis of 583 physician-reported errors. http://psnet.ahrq.gov/resource.aspx?resourceID=17084&rss=yes Schiff GD, Hasan O, Kim S, et al. Arch Intern Med. 2009;169:1881-1887. Disclosure of hospital adverse events and its association with patients' ratings of the quality of care. http://psnet.ahrq.gov/resource.aspx?resourceID=17085&rss=yes López L, Weissman JS, Schneider EC, Weingart SN, Cohen AP, Epstein AM. Arch Intern Med. 2009;169:1888-1894. Hospital governance and the quality of care. http://psnet.ahrq.gov/resource.aspx?resourceID=17065&rss=yes Jha AK, Epstein AM. Health Aff (Millwood). 2009 Nov 6; [Epub ahead of print]. Identifying organizational cultures that promote patient safety. http://psnet.ahrq.gov/resource.aspx?resourceID=17068&rss=yes Singer SJ, Falwell A, Gaba DM, et al. Health Care Manage Rev. 2009;34:300-311. Is there a relationship between high-quality performance in major teaching hospitals and residents' knowledge of quality and patient safety? http://psnet.ahrq.gov/resource.aspx?resourceID=17069&rss=yes Pingleton SK, Horak BJ, Davis DA, Goldmann DA, Keroack MA, Dickler RM. Acad Med. 2009;84:1510-1515. Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis. http://psnet.ahrq.gov/resource.aspx?resourceID=17073&rss=yes Singh H, Daci K, Petersen LA, et al. Am J Gastroenterol. 2009;104:2543-2554. Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training. http://psnet.ahrq.gov/resource.aspx?resourceID=17070&rss=yes Paull DE, Mazzia LM, Izu BS, Neily J, Mills PD, Bagian JP. Am J Surg. 2009;198:675-678. Quality and safety on an acute surgical ward: an exploratory cohort study of process and outcome. http://psnet.ahrq.gov/resource.aspx?resourceID=17067&rss=yes Kreckler S, Catchpole KR, New SJ, Handa A, McCulloch PG. Ann Surg. 2009 Oct 21; [Epub ahead of print]. Testing the association between Patient Safety Indicators and hospital structural characteristics in VA and nonfederal hospitals. http://psnet.ahrq.gov/resource.aspx?resourceID=17072&rss=yes Rivard PE, Elixhauser A, Christiansen CL, Zhao S, Rosen AK. Med Care Res Rev. 2009 Oct 30; [Epub ahead of print]. Medication Safety in the Operating Room: Time for a New Paradigm. http://psnet.ahrq.gov/resource.aspx?resourceID=17076&rss=yes Anesthesia Patient Safety Foundation. January 26, 2010; Royal Palms Resort and Spa, Phoenix, AZ. Patient Safety Conference 2010. http://psnet.ahrq.gov/resource.aspx?resourceID=11980&rss=yes GovNet Communications. February 4, 2010; QE II Conference Centre, London, UK. Changing course. http://psnet.ahrq.gov/resource.aspx?resourceID=17054&rss=yes DerGurahian J. Mod Healthc. November 2, 2009;39:6. Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions. http://psnet.ahrq.gov/resource.aspx?resourceID=17075&rss=yes ISMP Medication Safety Alert! Acute Care Edition. November 5, 2009;14:1-3. Safe Use Initiative. http://psnet.ahrq.gov/resource.aspx?resourceID=17077&rss=yes US Food and Drug Administration. 44th ASHP Midyear Clinical Meeting and Exhibition. http://psnet.ahrq.gov/resource.aspx?resourceID=11270&rss=yes American Society of Health-System Pharmacists. December 6-10, 2009; Venetian Hotels and Sands Expo Center, Las Vegas, NV. 12th Annual ISMP Cheers Awards. http://psnet.ahrq.gov/resource.aspx?resourceID=10705&rss=yes Institute for Safe Medication Practices. December 8, 2009; Bali Hai Golf Club, Las Vegas, NV.