-
psnet.ahrq.gov/node/35402/psn-pdf
September 10, 2009 - Can patients be part of the solution? Views on their role
in preventing medical errors.
September 10, 2009
Hibbard JH, Peters E, Slovic P, et al. Can patients be part of the solution? Views on their role in preventing
medical errors. Med Care Res Rev. 2005;62(5):601-16.
https://psnet.ahrq.gov/issue/can-patients-be…
-
psnet.ahrq.gov/node/44785/psn-pdf
January 27, 2016 - Reducing Adverse Drug Events Related to Opioids
Implementation Guide.
January 27, 2016
Frederickson TW. Gordon DB, De Pinto M, et al. Philadelphia, PA: Society of Hospital Medicine; 2015.
https://psnet.ahrq.gov/issue/reducing-adverse-drug-events-related-opioids-implementation-guide
Opioids are high-risk medication…
-
psnet.ahrq.gov/node/40097/psn-pdf
January 19, 2011 - Use of an electronic information system to identify
adverse events resulting in an emergency department
visit.
January 19, 2011
Ackroyd-Stolarz S, MacKinnon NJ, Zed PJ, et al. Use of an electronic information system to identify
adverse events resulting in an emergency department visit. Qual Saf Health Care. 2010;1…
-
psnet.ahrq.gov/node/47213/psn-pdf
June 20, 2018 - Are second victims getting the help they need?
June 20, 2018
Headley M. Patient Saf Qual Healthc. May/June 2018.
https://psnet.ahrq.gov/issue/are-second-victims-getting-help-they-need
Clinicians can experience emotional stress, guilt, and insecurity after making a mistake. Organizations are
increasingly building p…
-
psnet.ahrq.gov/node/50653/psn-pdf
November 13, 2019 - A national patient safety curriculum in pediatric
emergency medicine.
November 13, 2019
Stankovic C, Wolff M, Chang TP, et al. A National Patient Safety Curriculum in Pediatric Emergency
Medicine. Pediatr Emerg Care. 2019;35(8):519-521. doi:10.1097/PEC.0000000000001533.
https://psnet.ahrq.gov/issue/national-patien…
-
psnet.ahrq.gov/node/46278/psn-pdf
July 19, 2017 - The opioid epidemic: what can surgeons do about it?
July 19, 2017
Saluja S, Selzer D, Meara JG, et al. Bull Am Coll Surg. 2017;102(7):13-18.
https://psnet.ahrq.gov/issue/opioid-epidemic-what-can-surgeons-do-about-it
Surgeons often prescribe opioids for patients after procedures, so they are in a key position to ass…
-
psnet.ahrq.gov/node/50445/psn-pdf
October 09, 2019 - A demonstration project on the impact of safety culture
on infection control practices in hemodialysis
October 9, 2019
Millson T, Hackbarth D, Bernard HL. A demonstration project on the impact of safety culture on infection
control practices in hemodialysis. Am J Infect Control. 2019;47(9):1122-1129.
doi:10.1016/j…
-
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…
-
psnet.ahrq.gov/node/46025/psn-pdf
July 11, 2017 - Measuring to improve medication reconciliation in a large
subspecialty outpatient practice.
July 11, 2017
Kern E, Dingae MB, Langmack EL, et al. Measuring to Improve Medication Reconciliation in a Large
Subspecialty Outpatient Practice. Jt Comm J Qual Patient Saf. 2017;43(5):212-223.
doi:10.1016/j.jcjq.2017.02.005…
-
psnet.ahrq.gov/node/60764/psn-pdf
August 05, 2020 - As coronavirus ravaged nursing homes, inspectors were
not being tested.
August 5, 2020
Dolan J, Mejia B. As coronavirus ravaged nursing homes, inspectors were not being tested. Los Angeles
Times. 2020;July 24.
https://psnet.ahrq.gov/issue/coronavirus-ravaged-nursing-homes-inspectors-were-not-being-tested
Worker s…
-
psnet.ahrq.gov/node/45263/psn-pdf
September 04, 2016 - PSYCH: a mnemonic to help psychiatric residents
decrease patient handoff communication errors.
September 4, 2016
Mariano MT, Brooks V, DiGiacomo M. PSYCH: A Mnemonic to Help Psychiatric Residents Decrease
Patient Handoff Communication Errors. Jt Comm J Qual Patient Saf. 2016;42(7):316-320.
https://psnet.ahrq.gov/i…
-
psnet.ahrq.gov/node/74016/psn-pdf
October 27, 2021 - Malnutrition in Hospitalized Adults: A Systematic Review.
October 27, 2021
Uhl S, Siddique SM, McKeever L, et al. Rockville, MD: Agency for Healthcare Research and Quality;
October 2021. AHRQ Publication No. 21(22)-EHC035.
https://psnet.ahrq.gov/issue/malnutrition-hospitalized-adults-systematic-review
Patien…
-
psnet.ahrq.gov/node/38747/psn-pdf
September 16, 2009 - Examination of how a survey can spur culture changes
using a quality improvement approach: a region-wide
approach to determining a patient safety culture.
September 16, 2009
Pringle J, Weber RJ, Rice K, et al. Examination of how a survey can spur culture changes using a quality
improvement approach: a region-wide …
-
psnet.ahrq.gov/node/41117/psn-pdf
March 04, 2015 - The effectiveness of integrated health information
technologies across the phases of medication
management: a systematic review of randomized
controlled trials.
March 4, 2015
McKibbon A, Lokker C, Handler S, et al. The effectiveness of integrated health information technologies
across the phases of medication man…
-
psnet.ahrq.gov/node/36086/psn-pdf
June 14, 2011 - Sensemaking of patient safety risks and hazards.
June 14, 2011
Battles J, Dixon NM, Borotkanics RJ, et al. Sensemaking of patient safety risks and hazards. Health Serv
Res. 2006;41(4 Pt 2):1555-1575.
https://psnet.ahrq.gov/issue/sensemaking-patient-safety-risks-and-hazards
This commentary discusses the concept of …
-
psnet.ahrq.gov/node/45251/psn-pdf
August 24, 2016 - 5 cataract surgeries, 5 people blinded: what went wrong?
August 24, 2016
Kowalczyk L. Boston Globe. August 14, 2016.
https://psnet.ahrq.gov/issue/5-cataract-surgeries-5-people-blinded-what-went-wrong
Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on
a series o…
-
psnet.ahrq.gov/node/73429/psn-pdf
June 23, 2021 - Wrong Site Surgery - Wrong Patient: Invasive Procedures
in Outpatient Settings.
June 23, 2021
Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.
https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings
Wrong site/wrong patent surgery is a persisten…
-
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…
-
psnet.ahrq.gov/node/74117/psn-pdf
December 16, 2021 - New AHRQ SOPS® Workplace Safety Supplemental Items
for Hospitals.
November 24, 2021
Rockville, MD: Agency for Healthcare Research and Quality; December 16, 2021.
https://psnet.ahrq.gov/issue/new-ahrq-sopsr-workplace-safety-supplemental-items-hospitals
The release of the Workplace Safety supplemental items for…
-
psnet.ahrq.gov/node/60227/psn-pdf
April 15, 2020 - The next step in learning from sentinel events in
healthcare.
April 15, 2020
Bos K, Dongelmans DA, Greuters S, et al. The next step in learning from sentinel events in healthcare.
BMJ Open Qual. 2020;9(1):e000739. doi:10.1136/bmjoq-2019-000739.
https://psnet.ahrq.gov/issue/next-step-learning-sentinel-events-health…