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psnet.ahrq.gov/issue/selection-indicators-continuous-monitoring-patient-safety-recommendations-project-safety
June 22, 2016 - Commentary
Selection of indicators for continuous monitoring of patient safety: recommendations of the project 'safety improvement for patients in Europe.'
Citation Text:
Kristensen S, Mainz J, Bartels P. Selection of indicators for continuous monitoring of patient safety: recommendat…
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psnet.ahrq.gov/issue/handoffs-and-communication-underappreciated-roles-situational-awareness-and-inattentional
February 01, 2003 - Commentary
Handoffs and communication: the underappreciated roles of situational awareness and inattentional blindness.
Citation Text:
Gosbee JW. Handoffs and communication: the underappreciated roles of situational awareness and inattentional blindness. Clin Obstet Gynecol. 2010;53(3)…
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psnet.ahrq.gov/issue/patient-safety-intensive-care-results-multinational-sentinel-events-evaluation-see-study
March 03, 2011 - Study
Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study.
Citation Text:
Valentin A, Capuzzo M, Guidet B, et al. Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study. Intensive Care …
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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/adaptive-regulation-or-governmentality-patient-safety-and-changing-regulation-medicine
December 09, 2020 - Commentary
Adaptive regulation or governmentality: patient safety and the changing regulation of medicine.
Citation Text:
Waring J. Adaptive regulation or governmentality: patient safety and the changing regulation of medicine. Sociol Health Illn. 2007;29(2):163-79.
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psnet.ahrq.gov/issue/understanding-middle-managers-influence-implementing-patient-safety-culture
March 24, 2012 - Commentary
Understanding middle managers' influence in implementing patient safety culture.
Citation Text:
Gutberg J, Berta W. Understanding middle managers' influence in implementing patient safety culture. BMC Health Serv Res. 2017;17(1):582. doi:10.1186/s12913-017-2533-4.
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psnet.ahrq.gov/issue/exploring-barriers-learning-crisis-organizational-learning-and-crisis
January 08, 2025 - Review
Exploring the barriers to learning from crisis: organizational learning and crisis.
Citation Text:
Smith D, Elliott D. Exploring the Barriers to Learning from Crisis. Manag Learn. 2007;38(5):519-538. doi:10.1177/1350507607083205.
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psnet.ahrq.gov/issue/ashp-guidelines-preventing-medication-errors-chemotherapy-and-biotherapy
September 07, 2016 - Organizational Policy/Guidelines
ASHP guidelines on preventing medication errors with chemotherapy and biotherapy.
Citation Text:
Goldspiel B, Hoffman JM, Griffith NL, et al. ASHP guidelines on preventing medication errors with chemotherapy and biotherapy. Am J Health Syst Pharm. 2015;72…
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psnet.ahrq.gov/issue/cognitive-balanced-model-conceptual-scheme-diagnostic-decision-making
July 10, 2013 - Study
Cognitive balanced model: a conceptual scheme of diagnostic decision making.
Citation Text:
Lucchiari C, Pravettoni G. Cognitive balanced model: a conceptual scheme of diagnostic decision making. J Eval Clin Pract. 2012;18(1):82-8. doi:10.1111/j.1365-2753.2011.01771.x.
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psnet.ahrq.gov/issue/fallacy-single-diagnosis
October 05, 2022 - Study
The fallacy of a single diagnosis.
Citation Text:
Redelmeier DA, Shafir E. The fallacy of a single diagnosis. Med Decis Making. 2023;43(2):183-190. doi:10.1177/0272989x221121343.
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psnet.ahrq.gov/issue/inattentional-blindness-medicine
March 31, 2021 - Review
Inattentional blindness in medicine.
Citation Text:
Hults CM, Ding Y, Xie GG, et al. Inattentional blindness in medicine. Cogn Res Princ Implic. 2024;9(1):18. doi:10.1186/s41235-024-00537-x.
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psnet.ahrq.gov/issue/waiting-urgent-procedures-weekend-among-emergently-hospitalized-patients
September 04, 2019 - Study
Waiting for urgent procedures on the weekend among emergently hospitalized patients.
Citation Text:
Bell CM, Redelmeier DA. Waiting for urgent procedures on the weekend among emergently hospitalized patients. Am J Med. 2004;117(3):175-81.
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psnet.ahrq.gov/issue/effect-safe-zone-nurse-interruptions-distractions-and-medication-administration-errors
October 19, 2022 - Study
The effect of a safe zone on nurse interruptions, distractions, and medication administration errors.
Citation Text:
Yoder M, Schadewald D, Dietrich K. The effect of a safe zone on nurse interruptions, distractions, and medication administration errors. J Infus Nurs. 2015;38(2):140…
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psnet.ahrq.gov/issue/medical-error-reduction-and-tort-reform-through-private-contractually-based-quality-medicine
October 13, 2010 - Commentary
Medical error reduction and tort reform through private contractually-based quality medicine societies.
Citation Text:
MacCourt D, Bernstein J. Medical error reduction and tort reform through private, contractually-based quality medicine societies. Am J Law Med. 2009;35(4):5…
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psnet.ahrq.gov/issue/recasting-rca-improved-model-performing-root-cause-analyses
November 10, 2010 - Commentary
ReCASTing the RCA: an improved model for performing root cause analyses.
Citation Text:
Pham JC, Kim GR, Natterman JP, et al. ReCASTing the RCA: An Improved Model for Performing Root Cause Analyses. American Journal of Medical Quality. 2010;25(3). doi:10.1177/1062860609359533…
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psnet.ahrq.gov/issue/case-study-getting-boards-board-allen-memorial-hospital-iowa-health-system
August 04, 2021 - Commentary
Case study: getting boards on board at Allen Memorial Hospital, Iowa Health System.
Citation Text:
Slessor SR, Crandall JB, Nielsen GA. Case study: getting boards on board at Allen Memorial Hospital, Iowa Health System. Jt Comm J Qual Patient Saf. 2008;34(4):221-227.
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psnet.ahrq.gov/issue/unprofessional-behavior-leads-complications
October 31, 2023 - Audiovisual Presentation
Unprofessional Behavior Leads to Complications.
Citation Text:
Unprofessional Behavior Leads to Complications. JN Learning. 2020.
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psnet.ahrq.gov/issue/global-priorities-patient-safety-research
April 05, 2017 - Commentary
Global priorities for patient safety research.
Citation Text:
Bates DW, Larizgoitia I, Prasopa-Plaizier N, et al. Global priorities for patient safety research. BMJ. 2009;338:b1775. doi:10.1136/bmj.b1775.
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psnet.ahrq.gov/node/43658/psn-pdf
December 19, 2014 - https://psnet.ahrq.gov/primer/handoffs-and-signouts
https://psnet.ahrq.gov/issue/interprofessional-approaches-patient-safety
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psnet.ahrq.gov/node/44702/psn-pdf
December 16, 2015 - that contribute to alarm
fatigue, this review outlines technical, organizational, and educational approaches