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psnet.ahrq.gov/node/47903/psn-pdf
January 01, 2021 - A qualitative analysis of outpatient medication use in
community settings: observed safety vulnerabilities and
recommendations for improved patient safety.
April 17, 2019
Lyson HC, Sharma AE, Cherian R, et al. A Qualitative Analysis of Outpatient Medication Use in Community
Settings: Observed Safety Vulnerabilitie…
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psnet.ahrq.gov/node/46002/psn-pdf
October 13, 2018 - Exploring physician perspectives of residency holdover
handoffs: a qualitative study to understand an
increasingly important type of handoff.
October 13, 2018
Duong JA, Jensen TP, Morduchowicz S, et al. Exploring Physician Perspectives of Residency Holdover
Handoffs: A Qualitative Study to Understand an Increasing…
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psnet.ahrq.gov/node/866955/psn-pdf
October 16, 2024 - Adverse diagnostic events in hospitalised patients: a
single-centre, retrospective cohort study.
October 16, 2024
Dalal AK, Plombon S, Konieczny K, et al. Adverse diagnostic events in hospitalised patients: a single-
centre, retrospective cohort study. BMJ Qual Saf. 2024;Epub Oct 1. doi:10.1136/bmjqs-2024-017183.
…
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psnet.ahrq.gov/node/60233/psn-pdf
April 15, 2020 - Identifying safety hazards associated with intravenous
vancomycin through the analysis of patient safety event
reports.
April 15, 2020
Krukas A, Franklin ES, Bonk C, et al. Identifying safety hazards associated with intravenous vancomycin
through the analysis of patient safety event reports. Patient Safety. 2020;2…
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psnet.ahrq.gov/node/73164/psn-pdf
April 21, 2021 - Effectiveness of communication interventions in
obstetrics--a systematic review.
April 21, 2021
Lippke S, Derksen C, Keller FM, et al. Effectiveness of communication interventions in obstetrics--a
systematic review. Int J Environ Res Public Health. 2021;18(5):2616. doi:10.3390/ijerph18052616.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/41166/psn-pdf
February 29, 2012 - Triangulating case-finding tools for patient safety
surveillance: a cross-sectional case study of
puncture/laceration.
February 29, 2012
Taylor JA, Gerwin D, Morlock L, et al. Triangulating case-finding tools for patient safety surveillance: a
cross-sectional case study of puncture/laceration. Inj Prev. 2011;17(6)…
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psnet.ahrq.gov/node/47400/psn-pdf
November 28, 2018 - Impact of the communication and patient hand-off tool
SBAR on patient safety: a systematic review.
November 28, 2018
Müller M, Jürgens J, Redaèlli M, et al. Impact of the communication and patient hand-off tool SBAR on
patient safety: a systematic review. BMJ Open. 2018;8(8):e022202. doi:10.1136/bmjopen-2018-022202…
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psnet.ahrq.gov/node/839315/psn-pdf
January 01, 2024 - Six major steps to make investigations of suicide valuable
for learning and prevention.
November 2, 2022
Fröding E, Vincent C, Andersson-Gäre B, et al. Six major steps to make investigations of suicide valuable
for learning and prevention. Arch Suicide Res. 2024;28(1):1-19. doi:10.1080/13811118.2022.2133652.
https…
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psnet.ahrq.gov/node/38064/psn-pdf
February 23, 2009 - Same system, different outcomes: comparing the
transitions from two paper-based systems to the same
computerized physician order entry system.
February 23, 2009
Niazkhani Z, van der Sijs H, Pirnejad H, et al. Same system, different outcomes: comparing the transitions
from two paper-based systems to the same comput…
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psnet.ahrq.gov/node/60649/psn-pdf
July 01, 2020 - The differences between human error, at-risk behavior,
and reckless behavior are key to a just culture.
July 1, 2020
The differences between human error, at-risk behavior, and reckless behavior are key to a just culture.
ISMP Medication Safety Alert! Acute Care Edition. June 2020;25(12).
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/44898/psn-pdf
November 23, 2016 - Types and patterns of safety concerns in home care:
client and family caregiver perspectives.
November 23, 2016
Tong CE, Sims-Gould J, Martin-Matthews A. Types and patterns of safety concerns in home care: client
and family caregiver perspectives. Int J Qual Health Care. 2016;28(2):214-220.
doi:10.1093/intqhc/mzw0…
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psnet.ahrq.gov/node/74241/psn-pdf
January 12, 2022 - Validation of the second victim experience and support
tool-revised in the neonatal intensive care unit.
January 12, 2022
Winning AM, Merandi J, Rausch JR, et al. Validation of the second victim experience and support tool-
revised in the neonatal intensive care unit. J Patient Saf. 2021;17(8):531-540.
doi:10.1097…
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psnet.ahrq.gov/node/72600/psn-pdf
December 23, 2020 - Improving hospital safety culture for falls prevention
through interdisciplinary health education.
December 23, 2020
Lopez-Jeng C, Eberth SD. Improving hospital safety culture for falls prevention through interdisciplinary
health education. Health Promot Pract. 2020;21(6):918-925. doi:10.1177/1524839919840337.
htt…
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psnet.ahrq.gov/node/73470/psn-pdf
July 07, 2021 - Hospital quality-review spending and patient safety: a
longitudinal analysis using instrumental variables.
July 7, 2021
Dynan L, Smith RB. Hospital quality-review spending and patient safety: a longitudinal analysis using
instrumental variables. Health Serv Outcomes Res Methodol. 2021. doi:10.1007/s10742-021-00251-…
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psnet.ahrq.gov/node/45848/psn-pdf
November 19, 2018 - New Horizons in Patient Safety: Understanding
Communication: Case Studies for Physicians.
November 19, 2018
Hannawa AF, Wu AW, Juhasz RS, eds. Berlin, Germany: DeGruyter; 2017. ISBN: 9783110455014.
https://psnet.ahrq.gov/issue/new-horizons-patient-safety-understanding-communication-case-studies-
physicians
Poor c…
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psnet.ahrq.gov/node/865583/psn-pdf
April 17, 2024 - Impact of repeated reimbursement penalties on hospital
total quality scores.
April 17, 2024
Brewer A, Hughes MC, Patel KN. Impact of repeated reimbursement penalties on hospital total quality
scores. J Patient Saf. 2024;20(3):198-201. doi:10.1097/pts.0000000000001199.
https://psnet.ahrq.gov/issue/impact-repeated-r…
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psnet.ahrq.gov/node/47219/psn-pdf
July 25, 2018 - Preparing clinicians for transitioning patients across care
settings and into the home through simulation.
July 25, 2018
Molloy MA, Cary MP, Brennan-Cook J, et al. Preparing Clinicians for Transitioning Patients Across Care
Settings and Into the Home Through Simulation. Home Healthc Now. 2018;36(4):225-231.
doi:10…
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psnet.ahrq.gov/node/42156/psn-pdf
April 03, 2013 - The effect of a checklist on the quality of post-
anaesthesia patient handover: a randomized controlled
trial.
April 3, 2013
Salzwedel C, Bartz H-J, Kühnelt I, et al. The effect of a checklist on the quality of post-anaesthesia patient
handover: a randomized controlled trial. Int J Qual Health Care. 2013;25(2):176…
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psnet.ahrq.gov/node/36118/psn-pdf
September 24, 2010 - Implementing patient safety practices in small ambulatory
care settings.
September 24, 2010
Schauberger CW, Larson P. Implementing patient safety practices in small ambulatory care settings. Jt
Comm J Qual Patient Saf. 2006;32(8):419-425.
https://psnet.ahrq.gov/issue/implementing-patient-safety-practices-small-amb…
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psnet.ahrq.gov/node/44210/psn-pdf
September 09, 2015 - The future of graduate medical education: a systems-
based approach to ensure patient safety.
September 9, 2015
Bagian JP. The Future of Graduate Medical Education: A Systems-Based Approach to Ensure Patient
Safety. Acad Med. 2015;90(9):1199-202. doi:10.1097/ACM.0000000000000824.
https://psnet.ahrq.gov/issue/futur…