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psnet.ahrq.gov/node/73447/psn-pdf
June 30, 2021 - Errors in adult trauma resuscitation: a systematic review.
June 30, 2021
Nikouline A, Quirion A, Jung JJ, et al. Errors in adult trauma resuscitation: a systematic review. CJEM.
2021;23:537–546. doi:10.1007/s43678-021-00118-7.
https://psnet.ahrq.gov/issue/errors-adult-trauma-resuscitation-systematic-review
Trauma …
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psnet.ahrq.gov/node/48072/psn-pdf
June 19, 2019 - Independent double checks: worth the effort if used
judiciously and properly.
June 19, 2019
ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24:1-7.
https://psnet.ahrq.gov/issue/independent-double-checks-worth-effort-if-used-judiciously-and-properly
Independent double checks can reduce risk of human …
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psnet.ahrq.gov/node/838639/psn-pdf
October 19, 2022 - Calibrate Dx: A Resource to Improve Diagnostic
Decisions.
October 19, 2022
Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication no. 22(23)-
0047-2-EF.
https://psnet.ahrq.gov/issue/calibrate-dx-resource-improve-diagnostic-decisions
Delayed, wrong, and missed diagnoses are commo…
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psnet.ahrq.gov/node/60951/psn-pdf
September 23, 2020 - A Guide to Patient Safety Improvement: Integrating
Knowledge Translation & Quality Improvement
Approaches.
September 23, 2020
Edmonton, Alberta; Canadian Patient Safety Institute: 2020. ISBN: 9781926541846.
https://psnet.ahrq.gov/issue/guide-patient-safety-improvement-integrating-knowledge-translation-quality-
im…
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psnet.ahrq.gov/node/35470/psn-pdf
July 10, 2008 - Prevention of fall-related injuries in long-term care: a
randomized controlled trial of staff education.
July 10, 2008
Ray WA, Taylor JA, Brown AK, et al. Prevention of fall-related injuries in long-term care: a randomized
controlled trial of staff education. Arch Intern Med. 2005;165(19):2293-8.
https://psnet.ahr…
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psnet.ahrq.gov/node/50374/psn-pdf
September 25, 2019 - Explainable artificial intelligence for safe intraoperative
decision support.
September 25, 2019
Gordon L, Grantcharov T, Rudzicz F. Explainable Artificial Intelligence for Safe Intraoperative Decision
Support. JAMA Surg. 2019. doi:10.1001/jamasurg.2019.2821.
https://psnet.ahrq.gov/issue/explainable-artificial-int…
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psnet.ahrq.gov/node/44475/psn-pdf
October 03, 2017 - Scoring no goal—further adventures in transparency.
October 3, 2017
Rosenbaum L. Scoring No Goal--Further Adventures in Transparency. N Engl J Med. 2015;373(15):1385-
8. doi:10.1056/NEJMp1510094.
https://psnet.ahrq.gov/issue/scoring-no-goal-further-adventures-transparency
This commentary explores challenges to mon…
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psnet.ahrq.gov/node/46882/psn-pdf
May 23, 2018 - How health care changes when algorithms start making
diagnoses.
May 23, 2018
Burt A, Volchenboum S. Harv Bus Rev. May 8, 2018.
https://psnet.ahrq.gov/issue/how-health-care-changes-when-algorithms-start-making-diagnoses
Use of artificial intelligence and computer algorithms as tools to improve diagnosis have both r…
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psnet.ahrq.gov/node/72583/psn-pdf
December 16, 2020 - Wear face masks with no metal during MRI exams.
December 16, 2020
FDA Safety Communication. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug
Administration; December 7, 2020.
https://psnet.ahrq.gov/issue/wear-face-masks-no-metal-during-mri-exams
Magnetic resonance imaging (MRI) requires patient prep…
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psnet.ahrq.gov/node/47342/psn-pdf
August 22, 2018 - The doctor doesn't listen to her. But the media is starting
to.
August 22, 2018
Fetters A. The Atlantic. August 10, 2018.
https://psnet.ahrq.gov/issue/doctor-doesnt-listen-her-media-starting
Women face implicit bias that can affect the safety and effectiveness of their care. Reviewing several high-
profile accoun…
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psnet.ahrq.gov/node/849333/psn-pdf
May 24, 2023 - Patient safety in home health care: a grounded theory
study.
May 24, 2023
Shahrestanaki SK, Rafii F, Najafi Ghezeljeh T, et al. Patient safety in home health care: a grounded theory
study. BMC Health Serv Res. 2023;23(1):467. doi:10.1186/s12913-023-09458-9.
https://psnet.ahrq.gov/issue/patient-safety-home-health-c…
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psnet.ahrq.gov/node/36087/psn-pdf
September 28, 2010 - Improving patient safety in hospitals: contributions of
high-reliability theory and normal accident theory.
September 28, 2010
Tamuz M, Harrison MI. Improving patient safety in hospitals: Contributions of high-reliability theory and
normal accident theory. Health Serv Res. 2006;41(4 Pt 2):1654-76.
https://psnet.ah…
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psnet.ahrq.gov/node/43458/psn-pdf
August 27, 2014 - Validation of a teamwork perceptions measure to increase
patient safety.
August 27, 2014
Keebler JR, Dietz AS, Lazzara EH, et al. Validation of a teamwork perceptions measure to increase patient
safety. BMJ Qual Saf. 2014;23(9):718-26. doi:10.1136/bmjqs-2013-001942.
https://psnet.ahrq.gov/issue/validation-teamwork…
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psnet.ahrq.gov/node/46331/psn-pdf
September 14, 2018 - Health IT Patient Safety Supplemental Items for Hospitals.
September 14, 2018
Agency for Healthcare Research and Quality. July 25, 2018.
https://psnet.ahrq.gov/issue/health-it-patient-safety-supplemental-items-hospitals
Tracking the intersection of organizational culture with health information technology use can …
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psnet.ahrq.gov/node/41449/psn-pdf
February 13, 2019 - Just Culture and its critical link to patient safety—part 1
and part 2.
February 13, 2019
ISMP Medication Safety Alert! Acute Care Edition. May 17, 2012;17:1-4; July 12, 2012;17:1-3.
https://psnet.ahrq.gov/issue/just-culture-and-its-critical-link-patient-safety-part-1-and-part-2
This newsletter article series pres…
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psnet.ahrq.gov/node/33693/psn-pdf
February 01, 2010 - The Role of Graduate Medical Education (GME) in
Improving Patient Safety
February 1, 2010
Baron RB, Vidyarthi A. The Role of Graduate Medical Education (GME) in Improving Patient Safety. PSNet
[internet]. 2010.
https://psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
Perspec…
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psnet.ahrq.gov/node/846770/psn-pdf
March 29, 2023 - Procedure Complications – Who is Responsible for
Follow up?
March 29, 2023
Chalupsky M, Wei H, Marquet E. Procedure Complications – Who is Responsible for Follow up? PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow
The Case
A 74-year-old man with newly diagnose…
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psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it
October 01, 2017 - Preventing PICC Complications: Whose Line Is It?
Citation Text:
Moureau N. Preventing PICC Complications: Whose Line Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/medical-devices-wild
March 27, 2024 - Medical Devices in the "Wild"
Citation Text:
Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/inflicting-confusion
August 04, 2021 - Inflicting Confusion
Citation Text:
Scott FI, Lichtenstein GR. Inflicting Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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