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psnet.ahrq.gov/node/35696/psn-pdf
July 13, 2010 - Readiness to report medical treatment errors: the effects
of safety procedures, safety information, and priority of
safety.
July 13, 2010
Naveh E, Katz-Navon T, Stern Z. Readiness to report medical treatment errors: the effects of safety
procedures, safety information, and priority of safety. Med Care. 2006;44(2):…
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psnet.ahrq.gov/node/851645/psn-pdf
July 26, 2023 - Anticoagulation-associated adverse drug events in
hospitalized patients across two time periods.
July 26, 2023
Fanikos J, Tawfik Y, Almheiri D, et al. Anticoagulation-associated adverse drug events in hospitalized
patients across two time periods. Am J Med. 2023;136(9):927-936. doi:10.1016/j.amjmed.2023.05.013.
ht…
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psnet.ahrq.gov/node/47554/psn-pdf
November 07, 2018 - Diagnostic Excellence Initiative.
November 7, 2018
Gordon and Betty Moore Foundation.
https://psnet.ahrq.gov/issue/diagnostic-excellence-improving-experience-and-outcomes-patient-care
Missed or delayed diagnoses lead to delays in care and significant preventable harm for patients. Despite
an increasing focus on di…
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psnet.ahrq.gov/node/45699/psn-pdf
December 21, 2016 - Towards a new paradigm in laboratory medicine: the five
rights.
December 21, 2016
Plebani M. Towards a new paradigm in laboratory medicine: the five rights. Clin Chem Lab Med.
2016;54(12):1881-1891. doi:10.1515/cclm-2016-0848.
https://psnet.ahrq.gov/issue/towards-new-paradigm-laboratory-medicine-five-rights
Error…
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psnet.ahrq.gov/node/46290/psn-pdf
January 01, 2021 - Using prospective risk analysis tools to improve safety in
pharmacy settings: a systematic review and critical
appraisal.
August 2, 2017
Stojkovic T, Marinkovic V, Manser T. Using Prospective Risk Analysis Tools to Improve Safety in Pharmacy
Settings: A Systematic Review and Critical Appraisal. J Patient Saf. 2021…
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psnet.ahrq.gov/node/836919/psn-pdf
April 13, 2022 - Psychological intervention to improve communication
and patient safety in obstetrics: examination of the health
action process approach.
April 13, 2022
Derksen C, Kötting L, Keller FM, et al. Psychological intervention to improve communication and patient
safety in obstetrics: examination of the health action proc…
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psnet.ahrq.gov/node/837890/psn-pdf
August 24, 2022 - Accuracy of pressure ulcer events in US nursing home
ratings.
August 24, 2022
Chen Z, Gleason LJ, Sanghavi P. Accuracy of pressure ulcer events in US nursing home ratings. Med
Care. 2022;60(10):775-783. doi:10.1097/mlr.0000000000001763.
https://psnet.ahrq.gov/issue/accuracy-pressure-ulcer-events-us-nursing-home-ra…
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psnet.ahrq.gov/node/842428/psn-pdf
January 11, 2023 - The development of the concept of return-on-investment
from large-scale quality improvement programmes in
healthcare: an integrative systematic literature review.
January 11, 2023
Thusini S’thembile, Milenova M, Nahabedian N, et al. The development of the concept of return-on-
investment from large-scale quality i…
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psnet.ahrq.gov/node/45256/psn-pdf
July 01, 2017 - Applied use of safety event occurrence control charts of
harm and non-harm events: a case study.
July 1, 2017
Robinson SN, Neyens DM, Diller T. Applied Use of Safety Event Occurrence Control Charts of Harm and
Non-Harm Events: A Case Study. Am J Med Qual. 2017;32(3):285-291. doi:10.1177/1062860616646197.
https://p…
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psnet.ahrq.gov/node/44390/psn-pdf
July 18, 2016 - Should medical errors be disclosed to pediatric patients?
Pediatricians' attitudes toward error disclosure.
July 18, 2016
Kolaitis IN, Schinasi DA, Ross LF. Should Medical Errors Be Disclosed to Pediatric Patients? Pediatricians'
Attitudes Toward Error Disclosure. Acad Pediatr. 2016;16(5):482-488. doi:10.1016/j.aca…
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psnet.ahrq.gov/node/36539/psn-pdf
March 03, 2011 - Sensitivity of routine system for reporting patient safety
incidents in an NHS hospital: retrospective patient case
note review.
March 3, 2011
Sari AB-A, Sheldon T, Cracknell A, et al. Sensitivity of routine system for reporting patient safety incidents
in an NHS hospital: retrospective patient case note review. B…
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psnet.ahrq.gov/node/47083/psn-pdf
June 21, 2018 - Accuracy of skin cancer diagnosis by physician
assistants compared with dermatologists in a large health
care system.
June 21, 2018
Anderson AM, Matsumoto M, Saul MI, et al. Accuracy of Skin Cancer Diagnosis by Physician Assistants
Compared With Dermatologists in a Large Health Care System. JAMA Dermatol. 2018;154…
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psnet.ahrq.gov/node/863215/psn-pdf
February 28, 2024 - Learning from non-routine events and teamwork in
intensive care units: challenges and opportunities.
February 28, 2024
Gong Y, Chen Y. Learning from non-routine events and teamwork in intensive care units: challenges and
opportunities. Stud Health Technol Inform. 2024;310:324-328. doi:10.3233/shti230980.
https://p…
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psnet.ahrq.gov/node/45393/psn-pdf
November 16, 2016 - Agency for Healthcare Research and Quality (AHRQ)
Patient Safety Indicator for Postoperative Respiratory
Failure (PSI 11) does not identify accurately patients who
received unsafe care.
November 16, 2016
Nguyen MC, Moffatt-Bruce SD, Strosberg DS, et al. Agency for Healthcare Research and Quality (AHRQ)
Patient Sa…
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psnet.ahrq.gov/node/867234/psn-pdf
December 04, 2024 - Survey results reveal tubing misconnections are common
and underreported—Parts I and II.
December 4, 2024
Survey results reveal tubing misconnections are common and underreported—Parts I and II. ISMP
Medication Safety Alert! Acute Care. October 31, 2024;29(22 & 23):1-5;1-4.
https://psnet.ahrq.gov/issue/survey-resu…
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psnet.ahrq.gov/node/50913/psn-pdf
February 19, 2020 - "Disruptive behavior" in the operating room: A
prospective observational study of triggers and effects of
tense communication episodes in surgical teams.
February 19, 2020
Keller S, Tschan F, Semmer NK, et al. “Disruptive behavior” in the operating room: A prospective
observational study of triggers and effects of…
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psnet.ahrq.gov/node/35908/psn-pdf
March 03, 2011 - Patient safety in surgery.
March 3, 2011
Makary MA, Sexton B, Freischlag JA, et al. Patient safety in surgery. Ann Surg. 2006;243(5):628-32;
discussion 632-5.
https://psnet.ahrq.gov/issue/patient-safety-surgery
This AHRQ-supported study used a surgery-specific safety questionnaire (modified from the Safety
Attitu…
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psnet.ahrq.gov/node/36675/psn-pdf
January 18, 2011 - Target-focused medical emergency team training using a
human patient simulator: effects on behaviour and
attitude.
January 18, 2011
Wallin C-J, Meurling L, Hedman L, et al. Target-focused medical emergency team training using a human
patient simulator: effects on behaviour and attitude. Med Educ. 2007;41(2):173-80…
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psnet.ahrq.gov/node/46631/psn-pdf
March 20, 2018 - Simulation-based education to ensure provider
competency within the healthcare system.
March 20, 2018
Griswold S, Fralliccardi A, Boulet J, et al. Simulation-based Education to Ensure Provider Competency
Within the Health Care System. Acad Emerg Med. 2018;25(2):168-176. doi:10.1111/acem.13322.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/47034/psn-pdf
May 16, 2018 - Disruptive physician behavior: the importance of
recognition and intervention and its impact on patient
safety.
May 16, 2018
John PR, Heitt MC. Disruptive Physician Behavior: The Importance of Recognition and Intervention and Its
Impact on Patient Safety. J Hosp Med. 2018;13(3):210-212. doi:10.12788/jhm.2945.
htt…