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psnet.ahrq.gov/node/46510/psn-pdf
January 01, 2019 - Pediatric weight errors and resultant medication dosing
errors in the emergency department.
November 22, 2017
Hirata KM, Kang AH, Ramirez G, et al. Pediatric Weight Errors and Resultant Medication Dosing Errors in
the Emergency Department. Pediatr Emerg Care. 2019;35(9):637-642.
doi:10.1097/PEC.0000000000001277.
…
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psnet.ahrq.gov/node/74858/psn-pdf
February 23, 2022 - Improving responses to safety incidents: we need to talk
about justice.
February 23, 2022
Cribb A, O'Hara JK, Waring J. Improving responses to safety incidents: we need to talk about justice. BMJ
Qual Saf. 2022;31(4):327-330. doi:10.1136/bmjqs-2021-014333.
https://psnet.ahrq.gov/issue/improving-responses-safety-in…
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psnet.ahrq.gov/node/37120/psn-pdf
March 24, 2011 - Patient safety culture in primary care: developing a
theoretical framework for practical use.
March 24, 2011
Kirk S, Parker D, Claridge T, et al. Patient safety culture in primary care: developing a theoretical
framework for practical use. Qual Saf Health Care. 2007;16(4):313-20.
https://psnet.ahrq.gov/issue/patie…
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psnet.ahrq.gov/node/60020/psn-pdf
March 04, 2020 - The eNOTSS platform for surgeons’ nontechnical skills
performance improvement.
March 4, 2020
Pradarelli JC, Yule S, Smink DS. The eNOTSS Platform for Surgeons’ Nontechnical Skills Performance
Improvement. JAMA Surg. 2020;155(5):438-439. doi:10.1001/jamasurg.2019.5880.
https://psnet.ahrq.gov/issue/enotss-platform-s…
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psnet.ahrq.gov/node/35374/psn-pdf
January 02, 2017 - Intimidation: practitioners speak up about this unresolved
problem.
January 2, 2017
Smetzer JL, Cohen MR. Intimidation: Practitioners Speak Up About This Unresolved Problem. Jt Comm J
Qual Patient Saf. 2016;31(10):594-599. doi:10.1016/s1553-7250(05)31077-4.
https://psnet.ahrq.gov/issue/intimidation-practitioners-s…
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psnet.ahrq.gov/node/44170/psn-pdf
May 29, 2023 - Ambulatory Surgery Center Survey on Patient Safety
Culture.
May 29, 2023
Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
https://psnet.ahrq.gov/issue/ambulatory-surgery-center-survey-patient-safety-culture
Ambulatory surgery centers (ASCs) are increasingly being used to provide surgical ca…
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psnet.ahrq.gov/node/73077/psn-pdf
March 24, 2021 - Well-Being Playbook 2.0. A COVID-19 Resource for
Hospital and Health System Leaders.
March 24, 2021
AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021.
https://psnet.ahrq.gov/issue/well-being-playbook-20-covid-19-resource-hospital-and-health-system-leaders
Human factors enginee…
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psnet.ahrq.gov/node/44330/psn-pdf
September 02, 2015 - Health Literacy: Past, Present, and Future: Workshop
Summary.
September 2, 2015
Alper J; Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of
Medicine. Washington, DC: National Academies of Sciences, Engineering, and Medicine; 2015. ISBN:
9780309371544.
https://psnet.…
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psnet.ahrq.gov/node/38663/psn-pdf
May 27, 2009 - Prevention of retained surgical sponges: a decision-
analytic model predicting relative cost-effectiveness.
May 27, 2009
Regenbogen SE, Greenberg CC, Resch SC, et al. Prevention of retained surgical sponges: a decision-
analytic model predicting relative cost-effectiveness. Surgery. 2009;145(5):527-35.
doi:10.1016…
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psnet.ahrq.gov/node/42997/psn-pdf
May 28, 2014 - Exploring perinatal shift-to-shift handover communication
and process: an observational study.
May 28, 2014
Poot EP, de Bruijne M, Wouters MGAJ, et al. Exploring perinatal shift-to-shift handover communication and
process: an observational study. J Eval Clin Pract. 2014;20(2):166-75. doi:10.1111/jep.12103.
https:/…
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psnet.ahrq.gov/node/39356/psn-pdf
April 08, 2011 - Team training in the neonatal resuscitation program for
interns: teamwork and quality of resuscitations.
April 8, 2011
Thomas EJ, Williams AL, Reichman EF, et al. Team training in the neonatal resuscitation program for
interns: teamwork and quality of resuscitations. Pediatrics. 2010;125(3):539-546. doi:10.1542/ped…
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psnet.ahrq.gov/node/48028/psn-pdf
August 28, 2019 - Error Reduction and Prevention in Surgical Pathology,
Second Edition.
August 28, 2019
Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636.
https://psnet.ahrq.gov/issue/error-reduction-and-prevention-surgical-pathology-2nd-edition
Surgical specimen and laboratory process proble…
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psnet.ahrq.gov/node/50905/psn-pdf
February 19, 2020 - Patient activation related to fall prevention: a multisite
study
February 19, 2020
Christiansen TL, Lipsitz S, Scanlan M, et al. Patient activation related to fall prevention: a multisite study .
Jt Comm J Qual Patient Saf. 2020. doi:10.1016/j.jcjq.2019.11.010.
https://psnet.ahrq.gov/issue/patient-activation-relat…
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psnet.ahrq.gov/node/40350/psn-pdf
April 20, 2011 - Systemic vulnerabilities to suicide among veterans from
the Iraq and Afghanistan conflicts: review of case reports
from a national Veterans Affairs database.
April 20, 2011
Mills PD, Huber SJ, Watts BV, et al. Systemic vulnerabilities to suicide among veterans from the Iraq and
Afghanistan Conflicts: review of cas…
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psnet.ahrq.gov/node/45028/psn-pdf
May 25, 2016 - 'Just culture': improving safety by achieving substantive,
procedural and restorative justice.
May 25, 2016
Dekker SWA, Breakey H. ‘Just culture:’ Improving safety by achieving substantive, procedural and
restorative justice. Saf Sci. 2016;85. doi:10.1016/j.ssci.2016.01.018.
https://psnet.ahrq.gov/issue/just-cultu…
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psnet.ahrq.gov/node/39840/psn-pdf
September 15, 2010 - Wrong-site craniotomy: analysis of 35 cases and systems
for prevention.
September 15, 2010
Cohen FL, Mendelsohn D, Bernstein M. Wrong-site craniotomy: analysis of 35 cases and systems for
prevention. J Neurosurg. 2010;113(3):461-73. doi:10.3171/2009.10.JNS091282.
https://psnet.ahrq.gov/issue/wrong-site-craniotomy-…
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psnet.ahrq.gov/node/844793/psn-pdf
September 11, 2019 - PC standards for maternal safety.
September 11, 2019
The Joint Commission. R3 Report. August 21, 2019;24:1-6.
https://psnet.ahrq.gov/issue/pc-standards-maternal-safety
Maternal safety in the United States is gaining momentum as a system-level patient safety concern. This
report reviews the new Joint Commission Pro…
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psnet.ahrq.gov/node/45035/psn-pdf
January 23, 2017 - Premature closure? Not so fast.
January 23, 2017
Dhaliwal G. Premature closure? Not so fast. BMJ Qual Saf. 2017;26(2):87-89. doi:10.1136/bmjqs-2016-
005267.
https://psnet.ahrq.gov/issue/premature-closure-not-so-fast
Analyzing clinician decision making is increasingly suggested as a strategy to reduce diagnostic er…
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psnet.ahrq.gov/node/61123/psn-pdf
November 11, 2020 - Organizational Evidence-Based and Promising Practices
for Improving Clinician Well-Being.
November 11, 2020
Sinsky CA, Biddison LD, Mallick A, et al. NAM Perspectives. Washington DC: National Academy of
Medicine; 2020.
https://psnet.ahrq.gov/issue/organizational-evidence-based-and-promising-practices-improvin…
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psnet.ahrq.gov/node/46942/psn-pdf
September 24, 2018 - Measurement and monitoring of safety: impact and
challenges of putting a conceptual framework into
practice.
September 24, 2018
Chatburn E, Macrae C, Carthey J, et al. Measurement and monitoring of safety: impact and challenges of
putting a conceptual framework into practice. BMJ Qual Saf. 2018;27(10):818-826. doi…