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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;…
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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…
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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…
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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. …
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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…
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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…
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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…
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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…
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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/…
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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…
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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…
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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…
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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
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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
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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…
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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…
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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…
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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…
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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…
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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…