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psnet.ahrq.gov/node/39002/psn-pdf
January 03, 2017 - Engaging the patient as observer to promote hand
hygiene compliance in ambulatory care.
January 3, 2017
Bittle MJ, LaMarche S. Engaging the patient as observer to promote hand hygiene compliance in
ambulatory care. Jt Comm J Qual Patient Saf. 2009;35(10):519-25.
https://psnet.ahrq.gov/issue/engaging-patient-observ…
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psnet.ahrq.gov/node/38743/psn-pdf
January 03, 2017 - Refocusing the lens: patient safety in ambulatory chronic
disease care.
January 3, 2017
Sarkar U, Wachter R, Schroeder SA, et al. Refocusing the lens: patient safety in ambulatory chronic
disease care. Jt Comm J Qual Patient Saf. 2009;35(7):377-83, 341.
https://psnet.ahrq.gov/issue/refocusing-lens-patient-safety-a…
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psnet.ahrq.gov/node/45955/psn-pdf
January 01, 2021 - The essential role of leadership in developing a safety
culture.
April 3, 2017
The essential role of leadership in developing a safety culture. Sentinel Event Alert. 2021;57(57):1-8.
https://psnet.ahrq.gov/issue/essential-role-leadership-developing-safety-culture
The Joint Commission issues sentinel event alerts t…
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June 19, 2019 - Decisions and repercussions of second victim
experiences for mothers in medicine (SAVE DR MoM).
June 19, 2019
Gupta K, Lisker S, Rivadeneira NA, et al. Decisions and repercussions of second victim experiences for
mothers in medicine (SAVE DR MoM). BMJ Qual Saf. 2019;28(7):564-573. doi:10.1136/bmjqs-2018-
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January 01, 2020 - Psychological and psychosomatic symptoms of second
victims of adverse events: a systematic review and meta-
analysis.
May 1, 2019
Busch IM, Moretti F, Purgato M, et al. Psychological and Psychosomatic Symptoms of Second Victims of
Adverse Events. J Patient Saf. 2020;16(2):e61-e74. doi:10.1097/pts.0000000000000589.…
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psnet.ahrq.gov/node/47547/psn-pdf
February 13, 2019 - Prevention of prescription opioid misuse and projected
overdose deaths in the United States.
February 13, 2019
Chen Q, Larochelle MR, Weaver DT, et al. Prevention of Prescription Opioid Misuse and Projected
Overdose Deaths in the United States. JAMA Netw Open. 2019;2(2):e187621.
doi:10.1001/jamanetworkopen.2018.76…
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psnet.ahrq.gov/node/43533/psn-pdf
August 28, 2017 - Organizational, cultural, and psychological determinants
of smart infusion pump work arounds: a study of 3 U.S.
health systems.
August 28, 2017
Dunford BB, Perrigino M, Tucker SJ, et al. Organizational, Cultural, and Psychological Determinants of
Smart Infusion Pump Work Arounds: A Study of 3 U.S. Health Systems. …
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psnet.ahrq.gov/node/48061/psn-pdf
June 12, 2019 - Interventions to reduce burnout and improve resilience:
impact on a health system's outcomes.
June 12, 2019
Moffatt-Bruce SD, Nguyen MC, Steinberg B, et al. Interventions to Reduce Burnout and Improve
Resilience: Impact on a Health System's Outcomes. Clin Obstet Gynecol. 2019;62(3):432-443.
doi:10.1097/GRF.0000000…
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psnet.ahrq.gov/node/38288/psn-pdf
February 03, 2011 - Hospital-wide code rates and mortality before and after
implementation of a rapid response team.
February 3, 2011
Chan PS, Khalid A, Longmore LS, et al. Hospital-wide code rates and mortality before and after
implementation of a rapid response team. JAMA. 2008;300(21):2506-13. doi:10.1001/jama.2008.715.
https://ps…
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psnet.ahrq.gov/node/863747/psn-pdf
March 06, 2024 - "Good care is slow enough to be able to pay attention":
primary care time scarcity and patient safety.
March 6, 2024
Satterwhite S, Nguyen M-LT, Honcharov V, et al. "Good care is slow enough to be able to pay attention":
primary care time scarcity and patient safety. J Gen Intern Med. 2024;39(9):1575-1582.
doi:10.…
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psnet.ahrq.gov/node/39063/psn-pdf
December 17, 2009 - Safety and risk management interventions in hospitals: a
systematic review of the literature.
December 17, 2009
Dückers M, Faber M, Cruijsberg J, et al. Safety and risk management interventions in hospitals: a
systematic review of the literature. Med Care Res Rev. 2009;66(6 Suppl):90S-119S.
doi:10.1177/10775587093…
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psnet.ahrq.gov/node/40450/psn-pdf
December 21, 2014 - Unit-based care teams and the frequency and quality of
physician–nurse communications.
December 21, 2014
Gordon M, Melvin P, Graham DA, et al. Unit-based care teams and the frequency and quality of physician-
nurse communications. Arch Pediatr Adolesc Med. 2011;165(5):424-8. doi:10.1001/archpediatrics.2011.54.
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January 22, 2017 - A proactive risk avoidance system using failure mode and
effects analysis for "same-name" physician orders.
January 22, 2017
Tarpey K, Schaaf E, Lakhani U, et al. A proactive risk avoidance system using failure mode and effects
analysis for "same-name" physician orders. Jt Comm J Qual Patient Saf. 2010;36(10):461-7…
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psnet.ahrq.gov/node/48150/psn-pdf
August 21, 2019 - Communication between primary and secondary care:
deficits and danger.
August 21, 2019
Dinsdale E, Hannigan A, O’Connor R, et al. Communication between primary and secondary care: deficits
and danger. Fam Pract. 2019;17(1):63-68. doi:10.1093/fampra/cmz037.
https://psnet.ahrq.gov/issue/communication-between-primary…
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psnet.ahrq.gov/node/39001/psn-pdf
April 04, 2011 - Timely follow-up of abnormal diagnostic imaging test
results in an outpatient setting: are electronic medical
records achieving their potential?
April 4, 2011
Singh H, Thomas EJ, Mani S, et al. Timely follow-up of abnormal diagnostic imaging test results in an
outpatient setting: are electronic medical records ach…
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psnet.ahrq.gov/node/43514/psn-pdf
April 25, 2016 - A qualitative analysis of physician perspectives on
missed and delayed outpatient diagnosis: the focus on
system-related factors.
April 25, 2016
Sarkar U, Simchowitz B, Bonacum D, et al. A Qualitative Analysis of Physician Perspectives on Missed and
Delayed Outpatient Diagnosis: The Focus on System-Related Factors…
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psnet.ahrq.gov/node/40236/psn-pdf
March 23, 2012 - The safety implications of missed test results for
hospitalised patients: a systematic review.
March 23, 2012
Callen J, Georgiou A, Li J, et al. The safety implications of missed test results for hospitalised patients: a
systematic review. BMJ Qual Saf. 2011;20(2):194-199. doi:10.1136/bmjqs.2010.044339.
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December 21, 2022 - Detectability of medication errors with a STOPP/START-
based medication review in older people prior to a
potentially preventable drug-related hospital admission.
December 21, 2022
Sallevelt BTGM, Egberts TCG, Huibers CJA, et al. Detectability of medication errors with a STOPP/START-
based medication review in old…
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psnet.ahrq.gov/node/37032/psn-pdf
May 27, 2011 - Effects of computerized physician order entry and clinical
decision support systems on medication safety: a
systematic review.
May 27, 2011
Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision
support systems on medication safety: a systematic review. Arch Intern Me…
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psnet.ahrq.gov/node/47973/psn-pdf
July 18, 2019 - Transition planning for the senior surgeon: guidance and
recommendations from the Society of Surgical Chairs.
July 18, 2019
Rosengart TK, Doherty G, Higgins R, et al. Transition Planning for the Senior Surgeon: Guidance and
Recommendations From the Society of Surgical Chairs. JAMA Surg. 2019;154(7):647-653.
doi:10…