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1. How to prevent or reduce prescribing errors: an evidence brief for policy authors. | PSNet
   psnet.ahrq.gov/issue/how-prevent-or-reduce-prescribing-errors-evidence-brief-policy-authors
   July 27, 2022 - Review How to prevent or reduce prescribing errors: an evidence brief for policy authors … View more articles from the same authors.

2. Patient Safety Authority. | PSNet
   psnet.ahrq.gov/issue/patient-safety-authority
   May 22, 2023 - Multi-use Website Patient Safety Authority. Citation Text: Commonwealth of Pennsylvania Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL March 6, 2005 Commonwealth of Penns…

3. Periodic Issue | PSNet
   psnet.ahrq.gov/periodic-issue/periodic-issue-389
   April 26, 2023 - The authors of this article present a socioecological model for understanding the individual, interpersonal … The authors outline several recommendations for improving care, including workforce diversification, … The authors found the classes of medication related problems are similar to studies from a decade ago … Authors surmised that HCSWs may not be a substitute for RNs. … Authors surmised that HCSWs may not be a substitute for RNs.

4. Periodic Issue | PSNet
   psnet.ahrq.gov/periodic-issue/periodic-issue-284
   March 15, 2021 - The authors recommend creating policies restricting nurse shifts to no more than 12 hours per day and … The authors analyzed 24 checklists used in 18 Swiss hospitals, identified major differences between study … The authors suggest that future research should explore ways to improve the quality of surgical timeouts … The authors examined contributors to error-associated deaths occurring between 1996-2004 and 2005-2014 … The authors suggest that incorporating HIE data into reimbursement programs could promote more accurate

5. Periodic Issue | PSNet
   psnet.ahrq.gov/periodic-issue/periodic-issue-276
   January 29, 2021 - The authors found little evidence describing the role of healthcare workers in reducing or amplifying … Leveraging lessons learned from the pandemic, the authors use a human factors perspective to propose … The authors recommend several strategies for reducing wrong-patient errors.  … Leveraging lessons learned from the pandemic, the authors use a human factors perspective to propose … The authors found little evidence describing the role of healthcare workers in reducing or amplifying

6. Periodic Issue | PSNet
   psnet.ahrq.gov/periodic-issue/periodic-issue-300
   July 28, 2021 - The authors suggest that improvements in an organization’s health and wellness support programs could … To expand resident understanding of and participation in RCA, the authors developed simulated RCAs that … The authors suggest that improvements in an organization’s health and wellness support programs could … In a review of how regulators influence safety culture in several high-reliability fields, the authors … Using an example of a smart infusion pump, the authors discuss how to apply this concept in healthcare

7. Periodic Issue | PSNet
   psnet.ahrq.gov/periodic-issue/periodic-issue-280
   February 10, 2021 - Based on a review of the literature, the authors conclude that the strain placed on provider resources … The authors discuss implicit bias at the individual, organizational, educational, and research levels … In this evaluation of 194 cardiac catheterization procedures at a single hospital, the authors found … The authors propose several actions such as the use of a ‘sterile cockpit’ to reduce distractions and … Based on multistate data, the authors conclude that there is a disconnect between penalties levied by

8. Periodic Issue | PSNet
   psnet.ahrq.gov/periodic-issue/periodic-issue-384
   April 26, 2023 - The authors identify challenges that could be addressed to improve future educational interventions. … The authors concluded that virtual visits following cancer surgery had similar safety to in-person visits … The authors found that patient identification was not completed according to hospital policy during any … The authors highlight strategies to minimize the negative impacts of interruptions and strategies to … The authors identify challenges that could be addressed to improve future educational interventions.

9. Periodic Issue | PSNet
   psnet.ahrq.gov/periodic-issue/periodic-issue-318
   November 30, 2021 - The authors recommend additional prospective studies before using artificial intelligence in clinical … The authors identified an average of 5.9 patient safety incidents per 100 records/transports/patients … The authors discuss methodological challenges to preshopital care research and make recommendations for … The authors observe that questions remain about how clinicians are tailoring opioid reductions using … The authors observe that questions remain about how clinicians are tailoring opioid reductions using

10. Periodic Issue | PSNet
    psnet.ahrq.gov/periodic-issue/periodic-issue-328
    February 23, 2022 - The authors concluded that there are limited data describing diagnostic errors in pediatric hospital … The authors conducted a systematic review and meta-analysis of all types of adverse events, critical … The authors identified 21 generic diagnostic pitfall categories involving six different aspects of the … The authors conclude that approaches used in some prior research lacked internal validity and may not … The authors of this commentary discuss how the COVID-19 pandemic impacted high-reliability practices

11. Periodic Issue | PSNet
    psnet.ahrq.gov/periodic-issue/periodic-issue-299
    July 28, 2021 - The authors call for bold action emphasizing the need for structural changes.   … The authors apply this framework to a case of missed mass on breast imaging and discuss how its use can … The authors discuss how a systemic approach is required to situate these practitioners to provide the … The authors note that evidence does support that RRTs are associated with reduced secondary outcomes, … The authors call for bold action emphasizing the need for structural changes.  

12. Periodic Issue | PSNet
    psnet.ahrq.gov/periodic-issue/periodic-issue-291
    May 26, 2021 - The authors recommend these characteristics be considered when developing interventions to reduce PIMs … The authors suggest further examination of potentially biased data informing clinical prediction models … The authors suggest further examination of potentially biased data informing clinical prediction models … The authors recommend these characteristics be considered when developing interventions to reduce PIMs … The authors suggest SPADE could be used to compare sepsis diagnostic performance across institutions

13. A team performance measurement model for continuous improvement. | PSNet
    psnet.ahrq.gov/issue/team-performance-measurement-model-continuous-improvement
    August 30, 2023 - View more articles from the same authors. … The authors present a model that supports feedback processes for total quality teams to facilitate effective

14. Periodic Issue | PSNet
    psnet.ahrq.gov/periodic-issue/periodic-issue-287
    April 28, 2021 - Using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), the authors sought to determine … The authors emphasize the importance of further evaluation of human-computer interaction. … The authors developed and pilot-tested a debriefing tool to broaden the traditional focus of debriefs … The authors propose debriefing when things go right will increase debriefings overall. … The authors posit that this could be due to crowding or increasing care complexity due to age, frailty

15. COVID-19 Pandemic Impact on Healthcare Associated Conditions'NGtrtd
    psnet.ahrq.gov/curated-library/covid-19-pandemic-impact-healthcare-associated-conditionsngtrtd
    August 22, 2022 - The authors conclude that these findings suggest a need to return to conventional infection control … Based on retrospective data, the authors of this study did not identify a longitudinal increase in hospital-acquired … The authors discuss how prior organizational efforts to reduce hospital-acquired pressure injuries allowed

16. COVID-19 Pandemic Impact on Healthcare Associated Conditions | PSNet
    psnet.ahrq.gov/curated-library/covid-19-pandemic-impact-healthcare-associated-conditions
    September 08, 2022 - The authors conclude that these findings suggest a need to return to conventional infection control … Based on retrospective data, the authors of this study did not identify a longitudinal increase in hospital-acquired … The authors discuss how prior organizational efforts to reduce hospital-acquired pressure injuries allowed

17. Connie's Story: A Nurse's Personal Experience with MRSA | PSNet
    psnet.ahrq.gov/perspective/connies-story-nurses-personal-experience-mrsa
    April 30, 2024 - Experience with MRSA April 1, 2008  View more articles from the same authors … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not … None of the authors has any affiliation or financial involvement that conflicts with the material presented

18. Periodic Issue | PSNet
    psnet.ahrq.gov/periodic-issue/periodic-issue-275
    January 29, 2021 - The authors present several evidence-based strategies to reduce the likelihood of wrong-site surgery, … The authors recommend numerous key milestones, including improving measurement methods, routine monitoring … The authors present several evidence-based strategies to reduce the likelihood of wrong-site surgery, … The authors recommend numerous key milestones, including improving measurement methods, routine monitoring … In this systematic review, the authors found that information-based interventions (e.g., videos, offline

19. Periodic Issue | PSNet
    psnet.ahrq.gov/periodic-issue/periodic-issue-391
    April 26, 2023 - The authors outline several actions at the structural, institutional, and interpersonal levels to address … registered nurses working in the emergency department (ED) at one large academic health system, the authors … The authors outline several actions at the structural, institutional, and interpersonal levels to address … The authors in this article outline how implicit bias can affect health professional trainees and impact … The authors share steps taken to support success which include case selection, nonjudgmental culture,

20. Periodic Issue | PSNet
    psnet.ahrq.gov/periodic-issue/periodic-issue-296
    June 30, 2021 - Extrapolated nationally, the authors estimate the economic burden of nurse-sensitive adverse events to … Extrapolated nationally, the authors estimate the economic burden of nurse-sensitive adverse events to … The authors discuss strategies to reduce adverse events, including improving communication and information … The authors recommend that hospital and community healthcare staff perspectives be taken into account … The authors recommend further research into the association of burnout and patient safety using the MBI