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psnet.ahrq.gov/issue/seips-30-human-centered-design-patient-journey-patient-safety
September 11, 2019 - Review
Classic
SEIPS 3.0: human-centered design of the patient journey for patient safety.
Citation Text:
Carayon P, Wooldridge AR, Hoonakker P, et al. SEIPS 3.0: human-centered design of the patient journey for patient safety. App Ergon. 2020;84:103033. doi:10…
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psnet.ahrq.gov/issue/challenges-and-opportunities-improving-patient-safety-through-human-factors-and-systems
September 11, 2019 - Commentary
Emerging Classic
Challenges and opportunities for improving patient safety through human factors and systems engineering.
Citation Text:
Carayon P, Wooldridge A, Hose B-Z, et al. Challenges And Opportunities For Improving Patient Safety Through Human …
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psnet.ahrq.gov/issue/relationship-between-psychological-safety-and-reporting-nonadherence-safety-checklist
April 06, 2022 - Study
Relationship between psychological safety and reporting nonadherence to a safety checklist.
Citation Text:
Gilmartin HM, Langner P, Gokhale M, et al. Relationship Between Psychological Safety and Reporting Nonadherence to a Safety Checklist. J Nurs Care Qual. 2018;33(1):53-60. doi:…
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psnet.ahrq.gov/issue/nurse-burnout-predicts-self-reported-medication-administration-errors-acute-care-hospitals
August 25, 2021 - Study
Nurse burnout predicts self-reported medication administration errors in acute care hospitals.
Citation Text:
Montgomery AP, Azuero A, Baernholdt MB, et al. Nurse burnout predicts self-reported medication administration errors in acute care hospitals. J Healthc Qual. 2020;43(1):13…
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psnet.ahrq.gov/issue/reducing-risk-and-promoting-patient-safety-nih-intramural-clinical-research-draft-report
November 18, 2020 - Book/Report
Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical Research—Final Report.
Citation Text:
Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical Research—Final Report. The Clinical Center Working Group Report to the Advisory Committee to the…
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psnet.ahrq.gov/issue/long-term-sustainability-and-adaptation-i-pass-handovers
September 09, 2020 - Study
Long-term sustainability and adaptation of I-PASS handovers.
Citation Text:
Ryan SL, Logan M, Liu X, et al. Long-term sustainability and adaptation of I-PASS handovers. Jt Comm J Qual Patient Saf. 2023;19(12):689-697. doi:10.1016/j.jcjq.2023.07.007.
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psnet.ahrq.gov/web-mm/medical-devices-wild
March 27, 2024 - It is important to view this as an enabler for innovation rather than a barrier.
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psnet.ahrq.gov/issue/raising-barcode-improving-medication-safety-behaviours-through-behavioural-science-informed
November 01, 2023 - Study
Raising the barcode: improving medication safety behaviours through a behavioural science-informed feedback intervention. A quality improvement project and difference-in-difference analysis.
Citation Text:
Grailey K, Brazier A, Franklin BD, et al. Raising the barcode: improving med…
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psnet.ahrq.gov/issue/clinical-ict-systems-victorian-public-health-sector
September 08, 2010 - Book/Report
Clinical ICT Systems in the Victorian Public Health Sector.
Citation Text:
Clinical ICT Systems in the Victorian Public Health Sector. Doyle J. Melbourne, Australia: Victorian Auditor-General's Office; October 30, 2013.
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psnet.ahrq.gov/print/pdf/node/848754
January 01, 2025 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Implementation of Patient Safety Projects
Curated Library
Foundations
Leading change: why transformation efforts fail.
Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
Kotter, a professor at Harvard Business School, outlines the eight stages …
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psnet.ahrq.gov/issue/team-cognition-handoffs-relating-system-factors-team-cognition-functions-and-outcomes-two
February 16, 2022 - Study
Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes.
Citation Text:
Wooldridge AR, Carayon P, Hoonakker PLT, et al. Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two hand…
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psnet.ahrq.gov/issue/role-organizational-and-professional-cultures-medication-safety-scoping-review-literature
February 12, 2020 - Review
The role of organizational and professional cultures in medication safety: a scoping review of the literature.
Citation Text:
Machen S, Jani Y, Turner S, et al. The role of organizational and professional cultures in medication safety: a scoping review of the literature. Int J Hea…
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psnet.ahrq.gov/issue/moving-after-critical-incidents-health-care-qualitative-study-perspectives-and-experiences
February 10, 2021 - Study
Moving on after critical incidents in health care: a qualitative study of the perspectives and experiences of second victims
Citation Text:
Buhlmann M, Ewens B, Rashidi A. Moving on after critical incidents in health care: a qualitative study of the perspectives and experiences of …
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psnet.ahrq.gov/issue/grading-recommendations-enhanced-patient-safety-sentinel-event-analysis-recommendation
April 15, 2020 - Study
Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation improvement matrix.
Citation Text:
Bos K, van der Laan MJ, Groeneweg J, et al. Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation impro…
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psnet.ahrq.gov/issue/medication-dose-calculation-errors-and-other-numeracy-mishaps-hospitals-analysis-nature-and
May 11, 2022 - Study
Medication dose calculation errors and other numeracy mishaps in hospitals: analysis of the nature and enablers of incident reports.
Citation Text:
Mulac A, Hagesaether E, Granas AG. Medication dose calculation errors and other numeracy mishaps in hospitals: analysis of the nature …
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psnet.ahrq.gov/issue/leveraging-science-teamwork-sustain-handoff-improvements-cardiovascular-surgery
November 28, 2018 - Study
Leveraging the science of teamwork to sustain handoff improvements in cardiovascular surgery.
Citation Text:
Keebler JR, Lynch I, Ngo F, et al. Leveraging the science of teamwork to sustain handoff improvements in cardiovascular surgery. Jt Comm J Qual Patient Saf. 2023;49(8):373-3…
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psnet.ahrq.gov/issue/crisis-recovery-surgery-error-management-and-problem-solving-safety-critical-situations
November 30, 2022 - Study
Crisis recovery in surgery: error management and problem solving in safety-critical situations.
Citation Text:
Gogalniceanu P, Kunduzi B, Ruckley C, et al. Crisis recovery in surgery: error management and problem solving in safety-critical situations. Surgery. 2022;172(2):537-545. …
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psnet.ahrq.gov/issue/clinical-reasoning-dire-times-analysis-cognitive-biases-clinical-cases-during-covid-19
February 09, 2022 - Study
Clinical reasoning in dire times- analysis of cognitive biases in clinical cases during the COVID-19 pandemic.
Citation Text:
Coen M, Sader J, Junod-Perron N, et al. Clinical reasoning in dire times- analysis of cognitive biases in clinical cases during the COVID-19 pandemic. Inter…
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psnet.ahrq.gov/issue/study-multisite-prospective-adverse-event-surveillance-system
October 16, 2019 - Study
Study of a multisite prospective adverse event surveillance system.
Citation Text:
Forster AJ, Huang A, Lee TC, et al. Study of a multisite prospective adverse event surveillance system. BMJ Qual Saf. 2020;29(4). doi:10.1136/bmjqs-2018-008664.
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psnet.ahrq.gov/issue/systems-approach-health-service-design-delivery-and-improvement-systematic-review-and-meta
February 02, 2022 - Review
Emerging Classic
Systems approach to health service design, delivery and improvement: a systematic review and meta-analysis.
Citation Text:
Komashie A, Ward JR, Bashford T, et al. Systems approach to health service design, delivery and improvement: a syst…