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psnet.ahrq.gov/node/50784/psn-pdf
January 08, 2020 - Improving Quality of Care and Patient Outcomes During
Care Transitions (R01).
January 8, 2020
Rockville, MD: Agency for Healthcare Research and Quality; December 6, 2019. PA-20-068.
https://psnet.ahrq.gov/issue/improving-quality-care-and-patient-outcomes-during-care-transitions-r01
Communication during patient tra…
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psnet.ahrq.gov/node/49752/psn-pdf
January 01, 2016 - Inadvertent Use of More Potent Acid Leads to Burn
January 1, 2016
Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
The Case
A 31-year-old woman came to the clinic for a routine well-woman evaluation. She…
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psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
November 01, 2023 - Inadvertent Use of More Potent Acid Leads to Burn
Citation Text:
Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/issue/application-emergency-preparedness-principles-pharmacy-departments-approach-black-swan-event
July 22, 2020 - Commentary
Application of emergency preparedness principles to a pharmacy department’s approach to a “black swan” event: the COVID-19 pandemic.
Citation Text:
Waldron KM, Schenkat DH, Rao KV, et al. Application of emergency preparedness principles to a pharmacy department’s approach to a…
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psnet.ahrq.gov/issue/application-trigger-tools-detecting-adverse-drug-events-older-people-systematic-review-and
June 15, 2022 - Review
Application of trigger tools for detecting adverse drug events in older people: a systematic review and meta-analysis.
Citation Text:
Schiavo G, Forgerini M, Varallo FR, et al. Application of trigger tools for detecting adverse drug events in older people: a systematic review and …
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psnet.ahrq.gov/issue/applicability-healthcare-failure-mode-and-effects-analysis-healthcare-epidemiology-evaluation
October 19, 2022 - Study
Applicability of Healthcare Failure Mode and Effects Analysis to healthcare epidemiology: evaluation of the sterilization and use of surgical instruments.
Citation Text:
Weinstein RA, Linkin DR, Sausman C, et al. Applicability of Healthcare Failure Mode and Effects Analysis to Heal…
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psnet.ahrq.gov/issue/application-human-factors-methods-ensure-appropriate-infant-identification-and-abduction
April 27, 2022 - Commentary
Application of human factors methods to ensure appropriate infant identification and abduction prevention within the hospital setting.
Citation Text:
Webster KLW, Stikes R, Bunnell L, et al. Application of human factors methods to ensure appropriate infant identification and a…
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psnet.ahrq.gov/node/867445/psn-pdf
January 08, 2025 - Using human factors methods to mitigate bias in artificial
intelligence-based clinical decision support.
January 8, 2025
Militello LG, Diiulio J, Wilson DL, et al. Using human factors methods to mitigate bias in artificial
intelligence-based clinical decision support. J Am Med Inform Assoc. 2025;32(2):398-403.
doi…
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psnet.ahrq.gov/issue/validation-mobile-app-reducing-errors-administration-medications-emergency
September 23, 2020 - Study
Validation of a mobile app for reducing errors of administration of medications in an emergency.
Citation Text:
Baumann D, Dibbern N, Sehner S, et al. Validation of a mobile app for reducing errors of administration of medications in an emergency. J Clin Monit Comput. . 2019;33(3):…
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psnet.ahrq.gov/issue/engaging-patient-and-family-surgical-safety-process-utilizing-safestart
October 19, 2022 - Study
Engaging the patient and family in the surgical safety process utilizing SafeStart.
Citation Text:
Elger BM, Esparaz JR, Nierstedt RT, et al. Engaging the patient and family in the surgical safety process utilizing. J Pediatr Surg. 2020;55(4). doi:10.1016/j.jpedsurg.2019.06.012.
…
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psnet.ahrq.gov/issue/mistaken-identity-skin-cleansing-solution-leading-extensive-chemical-burns-extremely-preterm
October 19, 2022 - Commentary
Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infant.
Citation Text:
Mannan K, Chow P, Lissauer T, et al. Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infan…
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psnet.ahrq.gov/issue/grand-rounds-methodology-key-considerations-implementing-machine-learning-solutions-quality
July 26, 2023 - Commentary
Grand rounds in methodology: key considerations for implementing machine learning solutions in quality improvement initiatives.
Citation Text:
Verma AA, Trbovich PL, Mamdani MM, et al. Grand rounds in methodology: key considerations for implementing machine learning solutions …
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psnet.ahrq.gov/primer/triggers-and-trigger-tools
September 15, 2024 - The GTT includes 53 different triggers, some applicable to all patients and some inappropriate for certain
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psnet.ahrq.gov/node/49551/psn-pdf
December 01, 2007 - Too Hot For Comfort
December 1, 2007
Cleland H, Wasiak J. Too Hot For Comfort. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/too-hot-comfort
The Case
A 4-month-old infant admitted to rule out sepsis was receiving maintenance intravenous (IV) fluid and IV
antibiotics via a peripheral line in the left antec…
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psnet.ahrq.gov/node/862997/psn-pdf
February 21, 2024 - What kinds of insights do Safety-I and Safety-II
approaches provide? A critical reflection on the use of
SHERPA and FRAM in healthcare.
February 21, 2024
Sujan M, Lounsbury O, Pickup L, et al. What kinds of insights do Safety-I and Safety-II approaches
provide? A critical reflection on the use of SHERPA and FRAM i…
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psnet.ahrq.gov/issue/understanding-why-quality-initiatives-succeed-or-fail-sociotechnical-systems-perspective
March 10, 2021 - Commentary
Understanding why quality initiatives succeed or fail: a sociotechnical systems perspective.
Citation Text:
Wiegmann DA. Understanding Why Quality Initiatives Succeed or Fail: A Sociotechnical Systems Perspective. Ann Surg. 2016;263(1):9-11. doi:10.1097/SLA.0000000000001333.
…
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psnet.ahrq.gov/node/73699/psn-pdf
September 15, 2021 - Making safety training stickier: a richer model of safety
training engagement and transfer.
September 15, 2021
Casey T, Turner N, Hu X, et al. Making safety training stickier: a richer model of safety training engagement
and transfer. J Safety Res. 2021;78:303-313. doi:10.1016/j.jsr.2021.06.004.
https://psnet.ahrq…
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psnet.ahrq.gov/issue/measuring-handoff-quality-labor-and-delivery-development-validation-and-application
January 03, 2017 - Study
Measuring handoff quality in labor and delivery: development, validation, and application of the Coordination of Handoff Effectiveness Questionnaire (CHEQ).
Citation Text:
Block M, Ehrenworth JF, Cuce VM, et al. Measuring handoff quality in labor and delivery: development, valid…
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psnet.ahrq.gov/issue/duke-surgery-patient-safety-open-source-application-anonymous-reporting-adverse-and-near-miss
February 15, 2011 - Commentary
Duke Surgery Patient Safety: an open-source application for anonymous reporting of adverse and near-miss surgical events.
Citation Text:
Pietrobon R, Lima R, Shah A, et al. Duke Surgery Patient Safety: an open-source application for anonymous reporting of adverse and near-mi…
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psnet.ahrq.gov/node/47941/psn-pdf
January 01, 2020 - Usability and feasibility of consumer-facing technology to
reduce unsafe medication use by older adults.
May 22, 2019
Holden RJ, Campbell NL, Abebe E, et al. Usability and feasibility of consumer-facing technology to reduce
unsafe medication use by older adults. Res Social Adm Pharm. 2020;16(1):54-61.
doi:10.1016/…