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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/764396/psn-pdf
    March 02, 2022 - Family Input for Quality and Safety (FIQS): using mobile technology for in-hospital reporting from families and patients. March 2, 2022 Bardach NS, Stotts JR, Fiore DM, et al. Family Input for Quality and Safety (FIQS): Using mobile technology for in?hospital reporting from families and patients. J Hosp Med. 2022;…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43393/psn-pdf
    July 30, 2014 - Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model. July 30, 2014 Collins SJ, Newhouse R, Porter J, et al. Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model. AORN J…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44411/psn-pdf
    May 09, 2017 - Separating residents' inpatient and outpatient responsibilities: improving patient safety, learning environments, and relationships with continuity patients. May 9, 2017 Bates CK, Yang J, Huang GC, et al. Separating Residents' Inpatient and Outpatient Responsibilities: Improving Patient Safety, Learning Environmen…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42023/psn-pdf
    May 25, 2013 - Description and evaluation of adaptations to the Global Trigger Tool to enhance value to adverse event reduction efforts. May 25, 2013 Kennerly DA, Saldaña M, Kudyakov R, et al. Description and evaluation of adaptations to the global trigger tool to enhance value to adverse event reduction efforts. J Patient Saf. …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48085/psn-pdf
    June 19, 2019 - A decade of preventing harm. June 19, 2019 Woeltje KF, Olenski LK, Donatelli M, et al. A Decade of Preventing Harm. Jt Comm J Qual Patient Saf. 2019;45(7):480-486. doi:10.1016/j.jcjq.2019.04.007. https://psnet.ahrq.gov/issue/decade-preventing-harm Preventable patient safety problems continue to challenge health ca…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38760/psn-pdf
    July 08, 2009 - Nurses' perceptions of safety culture in long-term care settings. July 8, 2009 Wagner LM, Capezuti E, Rice JC. Nurses' perceptions of safety culture in long-term care settings. J Nurs Scholarsh. 2009;41(2):184-192. doi:10.1111/j.1547-5069.2009.01270.x. https://psnet.ahrq.gov/issue/nurses-perceptions-safety-culture…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42223/psn-pdf
    August 15, 2013 - Development of a checklist of safe discharge practices for hospital patients. August 15, 2013 Soong C, Daub S, Lee J, et al. Development of a checklist of safe discharge practices for hospital patients. J Hosp Med. 2013;8(8):444-9. doi:10.1002/jhm.2032. https://psnet.ahrq.gov/issue/development-checklist-safe-disch…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46361/psn-pdf
    May 23, 2018 - Inadequate hand-off communication. May 23, 2018 Inadequate hand-off communication. Sentinel event alert. 2017;58(58):1-6. https://psnet.ahrq.gov/issue/inadequate-hand-communication The Joint Commission publishes sentinel event alerts to draw attention to pressing or emerging safety issues and provide guidelines fo…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45461/psn-pdf
    January 03, 2017 - Operating room–to-ICU patient handovers: a multidisciplinary human-centered design approach. January 3, 2017 Segall N, Bonifacio AS, Barbeito A, et al. Operating Room-to-ICU Patient Handovers: A Multidisciplinary Human-Centered Design Approach. Jt Comm J Qual Patient Saf. 2016;42(9):400-14. https://psnet.ahrq.gov/…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41369/psn-pdf
    May 29, 2015 - Cognitive interventions to reduce diagnostic error: a narrative review. May 29, 2015 Graber ML, Kissam S, Payne VL, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf. 2012;21(7):535-557. doi:10.1136/bmjqs-2011-000149. https://psnet.ahrq.gov/issue/cognitive-interventions-re…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40473/psn-pdf
    July 02, 2011 - A systematic review of failures in handoff communication during intrahospital transfers. July 2, 2011 Ong M-S, Coiera E. A systematic review of failures in handoff communication during intrahospital transfers. Jt Comm J Qual Patient Saf. 2011;37(6):274-284. https://psnet.ahrq.gov/issue/systematic-review-failures-h…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866320/psn-pdf
    January 01, 2025 - Rapid response systems, antibiotic stewardship and medication reconciliation: a scoping review on implementation factors, activities and outcomes. July 17, 2024 Ohlsen JT, Søfteland E, Akselsen PE, et al. Rapid response systems, antibiotic stewardship and medication reconciliation: a scoping review on implementati…
  13. psnet.ahrq.gov/perspective/patient-and-family-roles-safety
    June 14, 2023 - The review notes that addressing these power imbalances is an important path forward for truly successful
  14. psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
    June 14, 2023 - The review notes that addressing these power imbalances is an important path forward for truly successful
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72618/psn-pdf
    December 23, 2020 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care December 23, 2020 https://psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards- medical-decisions Summary Nudges are a change in the way choices ar…
  16. psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
    August 05, 2009 - Discharge Instructions in the PACU: Who Remembers? Citation Text: Engel KG. Discharge Instructions in the PACU: Who Remembers?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar B…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33609/psn-pdf
    March 15, 2025 - Clinical Decision Support Systems March 15, 2025 Clinical Decision Support Systems. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/clinical-decision-support-systems PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46851/psn-pdf
    January 23, 2019 - To care is human—collectively confronting the clinician- burnout crisis. January 23, 2019 Dzau VJ, Kirch DG, Nasca TJ. To Care Is Human — Collectively Confronting the Clinician-Burnout Crisis. New Engl J Med. 2018;378(4):312-314. doi:10.1056/nejmp1715127. https://psnet.ahrq.gov/issue/care-human-collectively-confro…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45652/psn-pdf
    June 29, 2017 - Increases in drug and opioid overdose deaths—United States, 2000–2015. June 29, 2017 Rudd RA, Seth P, David F, et al. Increases in Drug and Opioid-Involved Overdose Deaths - United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(50-51):1445-1452. doi:10.15585/mmwr.mm655051e1. https://psnet.ahrq.gov/issue/inc…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43475/psn-pdf
    July 18, 2016 - A cross-sectional analysis investigating organizational factors that influence near-miss error reporting among hospital pharmacists. July 18, 2016 Patterson ME, Pace HA. A Cross-sectional Analysis Investigating Organizational Factors That Influence Near-Miss Error Reporting Among Hospital Pharmacists. J Patient Sa…

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