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psnet.ahrq.gov/node/45028/psn-pdf
May 25, 2016 - 'Just culture': improving safety by achieving substantive,
procedural and restorative justice.
May 25, 2016
Dekker SWA, Breakey H. ‘Just culture:’ Improving safety by achieving substantive, procedural and
restorative justice. Saf Sci. 2016;85. doi:10.1016/j.ssci.2016.01.018.
https://psnet.ahrq.gov/issue/just-cultu…
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psnet.ahrq.gov/node/60718/psn-pdf
July 22, 2020 - First Do No Harm. The Report of the Independent
Medicines and Medical Devices Safety Review.
July 22, 2020
Cumberlege J. London, England, Crown Copyright. July 8, 2020.
https://psnet.ahrq.gov/issue/first-do-no-harm-report-independent-medicines-and-medical-devices-safety-
review
Implicit biases are known to affect…
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psnet.ahrq.gov/node/854382/psn-pdf
October 11, 2023 - Battling alarm fatigue in the pediatric intensive care unit.
October 11, 2023
Herrera H, Wood D. Battling alarm fatigue in the pediatric intensive care unit. Crit Care Nurs Clin North Am.
2023;35(3):347-355. doi:10.1016/j.cnc.2023.05.003.
https://psnet.ahrq.gov/issue/battling-alarm-fatigue-pediatric-intensive-care-…
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psnet.ahrq.gov/node/837212/psn-pdf
June 08, 2022 - Engaging Physicians in Teamwork Training for Quality
and Safety - Or Why Don’t Your Physicians Get Engaged?
May 25, 2022
AHA Team Training. June 8, 2022.
https://psnet.ahrq.gov/issue/engaging-physicians-teamwork-training-quality-and-safety-or-why-dont-your-
physicians-get
Physicians are instrumental to the succes…
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psnet.ahrq.gov/node/34978/psn-pdf
June 30, 2011 - Personal digital assistant-based drug information
sources: potential to improve medication safety.
June 30, 2011
Galt K, Rule AM, Houghton B, et al. Personal digital assistant-based drug information sources: potential to
improve medication safety. J Med Libr Assoc. 2005;93(2):229-36.
https://psnet.ahrq.gov/issue/p…
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psnet.ahrq.gov/node/35899/psn-pdf
January 02, 2017 - Labeling solutions and medications in sterile procedural
settings.
January 2, 2017
Sheridan DJ. Labeling solutions and medications in sterile procedural settings. Jt Comm J Qual Patient
Saf. 2006;32(5):276-82.
https://psnet.ahrq.gov/issue/labeling-solutions-and-medications-sterile-procedural-settings
In response …
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psnet.ahrq.gov/node/46973/psn-pdf
June 25, 2018 - Balancing innovation and safety when integrating digital
tools into health care.
June 25, 2018
Auerbach AD, Neinstein A, Khanna R. Balancing Innovation and Safety When Integrating Digital Tools Into
Health Care. Ann Intern Med. 2018;168(10):733-734. doi:10.7326/M17-3108.
https://psnet.ahrq.gov/issue/balancing-inno…
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psnet.ahrq.gov/node/38456/psn-pdf
May 02, 2014 - Burden of difficult encounters in primary care: data from
the Minimizing Error, Maximizing Outcomes Study.
May 2, 2014
An PG, Rabatin JS, Manwell LB, et al. Burden of difficult encounters in primary care: data from the
minimizing error, maximizing outcomes study. Arch Intern Med. 2009;169(4):410-4.
doi:10.1001/arc…
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psnet.ahrq.gov/node/46751/psn-pdf
July 23, 2018 - A call for a systems-thinking approach to medication
adherence: stop blaming the patient.
July 23, 2018
Lauffenburger JC, Choudhry NK. A Call for a Systems-Thinking Approach to Medication Adherence: Stop
Blaming the Patient. JAMA Intern Med. 2018;178(7):950-951. doi:10.1001/jamainternmed.2018.0790.
https://psnet.a…
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psnet.ahrq.gov/node/41249/psn-pdf
December 21, 2014 - Physicians' needs in coping with emotional stressors: the
case for peer support.
December 21, 2014
Hu Y-Y, Fix ML, Hevelone ND, et al. Physicians' needs in coping with emotional stressors: the case for
peer support. Arch Surg. 2012;147(3):212-217. doi:10.1001/archsurg.2011.312.
https://psnet.ahrq.gov/issue/physici…
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psnet.ahrq.gov/node/839829/psn-pdf
November 09, 2022 - Pulse oximeters and their inaccuracies will get FDA
scrutiny today. What took so long?
November 9, 2022
McFarling UL. STAT. November 1, 2022.
https://psnet.ahrq.gov/issue/pulse-oximeters-and-their-inaccuracies-will-get-fda-scrutiny-today-what-took-
so-long
Evidence is building to delineate the effect of systemic …
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psnet.ahrq.gov/node/47408/psn-pdf
September 19, 2018 - Ways to Improve Electronic Health Record Safety.
September 19, 2018
Philadelphia, PA: Pew Charitable Trusts, American Medical Association, and Medstar Health; 2018.
https://psnet.ahrq.gov/issue/ways-improve-electronic-health-record-safety
Electronic health records both contribute to and detract from safe care. This…
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psnet.ahrq.gov/node/42382/psn-pdf
July 16, 2014 - Huddling for high reliability and situation awareness.
July 16, 2014
Goldenhar LM, Brady PW, Sutcliffe K, et al. Huddling for high reliability and situation awareness. BMJ Qual
Saf. 2013;22(11):899-906. doi:10.1136/bmjqs-2012-001467.
https://psnet.ahrq.gov/issue/huddling-high-reliability-and-situation-awareness
Se…
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psnet.ahrq.gov/node/46392/psn-pdf
October 13, 2018 - The clinical and medicolegal implications of radiology
results communication.
October 13, 2018
Aryal B, Khorsand DA, Dubinsky TJ. The Clinical and Medicolegal Implications of Radiology Results
Communication. Curr Probl Diagn Radiol. 2018;47(5):287-289. doi:10.1067/j.cpradiol.2017.09.009.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/38996/psn-pdf
March 04, 2011 - Overcoming barriers to the implementation of a pharmacy
bar code scanning system for medication dispensing: a
case study.
March 4, 2011
Nanji KC, Cina J, Patel N, et al. Overcoming barriers to the implementation of a pharmacy bar code
scanning system for medication dispensing: a case study. J Am Med Inform Assoc. …
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psnet.ahrq.gov/node/48006/psn-pdf
May 15, 2019 - Limits on opioid prescribing leave patients with chronic
pain vulnerable.
May 15, 2019
Rubin R. Limits on Opioid Prescribing Leave Patients With Chronic Pain Vulnerable. JAMA.
2019;321(21):2059-2062. doi:10.1001/jama.2019.5188.
https://psnet.ahrq.gov/issue/limits-opioid-prescribing-leave-patients-chronic-pain-vuln…
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psnet.ahrq.gov/node/44066/psn-pdf
September 21, 2016 - Raising an alarm, doctors fight to yank hospital ICUs into
the modern era.
September 21, 2016
McFarling UL. STAT. September 7, 2016.
https://psnet.ahrq.gov/issue/raising-alarm-doctors-fight-yank-hospital-icus-modern-era
Intensive care units (ICUs) are complex environments that harbor various challenges to safe car…
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psnet.ahrq.gov/node/50782/psn-pdf
January 08, 2020 - What can patient safety teach us about clinician burnout?
January 8, 2020
Wu AW, Dzau VJ. What Can Patient Safety Teach Us About Clinician Burnout? Ann Intern Med.
2019;171(12):933-934. doi:10.7326/m19-2397.
https://psnet.ahrq.gov/issue/what-can-patient-safety-teach-us-about-clinician-burnout
This commentary discu…
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psnet.ahrq.gov/node/43119/psn-pdf
April 16, 2014 - Still outside the bull's eye: 2014–2015 Targeted
Medication Safety Best Practices.
April 16, 2014
ISMP Medication Safety Alert! Acute care edition. March 27, 2014;19:1-5.
https://psnet.ahrq.gov/issue/still-outside-bulls-eye-2014-2015-targeted-medication-safety-best-practices
This newsletter article reports results…
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psnet.ahrq.gov/node/36769/psn-pdf
June 15, 2011 - Using incident reporting to improve patient safety: a
conceptual model.
June 15, 2011
Pronovost PJ, Holzmueller CG, Young J, et al. Using Incident Reporting to Improve Patient Safety. J
Patient Saf. 2008;3(1). doi:10.1097/pts.0b013e318030ca05.
https://psnet.ahrq.gov/issue/using-incident-reporting-improve-patient-s…