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psnet.ahrq.gov/node/44146/psn-pdf
June 03, 2015 - Transforming communication and safety culture in
intrapartum care: a multi-organization blueprint.
June 3, 2015
Lyndon A, Johnson C, Bingham D, et al. Transforming communication and safety culture in intrapartum
care: a multi-organization blueprint. Obstet Gynecol. 2015;125(5):1049-55.
doi:10.1097/AOG.000000000000…
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psnet.ahrq.gov/node/764400/psn-pdf
March 02, 2022 - A mixed methods evaluation of medication reconciliation
in the primary care setting.
March 2, 2022
Gionfriddo MR, Duboski V, Middernacht A, et al. A mixed methods evaluation of medication reconciliation
in the primary care setting. PLoS ONE. 2021;16(12):e0260882. doi:10.1371/journal.pone.0260882.
https://psnet.ahr…
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psnet.ahrq.gov/node/861284/psn-pdf
January 24, 2024 - Relationships among psychological safety, the principles
of high reliability, and safety reporting intentions in
pediatric nursing.
January 24, 2024
Pfeifer L, Vessey J, Cazzell M, et al. Relationships among psychological safety, the principles of high
reliability, and safety reporting intentions in pediatric nurs…
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psnet.ahrq.gov/node/60893/psn-pdf
January 01, 2021 - When safety event reporting is seen as punitive: "I've
been PSN-ed!"
September 9, 2020
Feeser VR, Jackson AK, Savage NM, et al. When safety event reporting is seen as punitive: "I've been
PSN-ed!". Ann Emerg Med. 2021;77(4):449-458. doi:10.1016/j.annemergmed.2020.06.048.
https://psnet.ahrq.gov/issue/when-safety-ev…
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psnet.ahrq.gov/node/73328/psn-pdf
May 26, 2021 - Care and Oversight Deficiencies Related to Multiple
Homicides at the Louis A. Johnson VA Medical Center in
Clarksburg, West Virginia.
May 26, 2021
Washington DC: Department of Veterans Affairs. Office of Inspector General; May 11, 2021. Report
No. 20-03593-140.
https://psnet.ahrq.gov/issue/care-and-oversigh…
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psnet.ahrq.gov/node/48069/psn-pdf
July 24, 2019 - Patient and visitor aggression in healthcare: a survey
exploring organisational safety culture and team efficacy.
July 24, 2019
Heckemann B, Hahn S, Halfens RJG, et al. Patient and visitor aggression in healthcare: A survey exploring
organisational safety culture and team efficacy. J Nurs Manag. 2019;27(5):1039-104…
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psnet.ahrq.gov/node/42862/psn-pdf
January 15, 2014 - VA Health Care: Improvements Needed in Processes
Used to Address Providers' Actions That Contribute to
Adverse Events.
January 15, 2014
Draper D. Washington, DC: United States Government Accountability Office; December 3, 2013.
Publication GAO-14-55.
https://psnet.ahrq.gov/issue/va-health-care-improvements-needed…
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psnet.ahrq.gov/node/855428/psn-pdf
November 15, 2023 - A study of error reporting by nurses: the significant
impact of nursing team dynamics.
November 15, 2023
Munn LT, Lynn MR, Knafl GJ, et al. A study of error reporting by nurses: the significant impact of nursing
team dynamics. J Res Nurs. 2023;28(5):354-364. doi:10.1177/17449871231194180.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/45034/psn-pdf
February 25, 2019 - Future directions for diagnostic decision support.
February 25, 2019
Carr S. ImproveDx. April 2016;3:1-3.
https://psnet.ahrq.gov/issue/future-directions-diagnostic-decision-support
Clinical decision support systems are tools being used to augment clinical reasoning and diagnostic
accuracy. This newsletter article …
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psnet.ahrq.gov/node/50423/psn-pdf
September 04, 2019 - When a vital sign leads a country astray—the opioid
epidemic.
September 4, 2019
Chidgey BA, McGinigle KL, McNaull PP. When a Vital Sign Leads a Country Astray—The Opioid Epidemic.
JAMA Surg. 2019;154(11):987-988. doi:10.1001/jamasurg.2019.2104.
https://psnet.ahrq.gov/issue/when-vital-sign-leads-country-astray-opio…
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psnet.ahrq.gov/node/836922/psn-pdf
April 13, 2022 - Exploration of prescribing error reporting across primary
care: a qualitative study.
April 13, 2022
Hall N, Bullen K, Sherwood J, et al. Exploration of prescribing error reporting across primary care: a
qualitative study. BMJ Open. 2022;12(1):e050283. doi:10.1136/bmjopen-2021-050283.
https://psnet.ahrq.gov/issue/e…
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psnet.ahrq.gov/node/42536/psn-pdf
August 13, 2014 - Levels of reflective thinking and patient safety: an
investigation of the mechanisms that impact on student
learning in a single cohort over a 5 year curriculum.
August 13, 2014
Ambrose LJ, Ker J. Levels of reflective thinking and patient safety: an investigation of the mechanisms that
impact on student learning i…
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psnet.ahrq.gov/node/43623/psn-pdf
September 29, 2017 - Intolerance of error and culture of blame drive medical
excess.
September 29, 2017
Hoffman JR, Kanzaria HK. Intolerance of error and culture of blame drive medical excess. BMJ.
2014;349(oct14 3). doi:10.1136/bmj.g5702.
https://psnet.ahrq.gov/issue/intolerance-error-and-culture-blame-drive-medical-excess
Lack of a…
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psnet.ahrq.gov/node/42834/psn-pdf
January 07, 2015 - Personal health records: a randomized trial of effects on
elder medication safety.
January 7, 2015
Chrischilles EA, Hourcade JP, Doucette W, et al. Personal health records: a randomized trial of effects on
elder medication safety. J Am Med Inform Assoc. 2014;21(4):679-86. doi:10.1136/amiajnl-2013-002284.
https://p…
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psnet.ahrq.gov/node/853628/psn-pdf
September 20, 2023 - How Columbia ignored women, undermined prosecutors
and protected a predator for more than 20 years.
September 20, 2023
Fortis B, Bell L. Pro Publica. September 12, 2023.
https://psnet.ahrq.gov/issue/how-columbia-ignored-women-undermined-prosecutors-and-protected-
predator-more-20-years
Sexual abuse of a patient i…
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psnet.ahrq.gov/node/46383/psn-pdf
September 20, 2017 - Prescription Drug Monitoring Programs: Evolution and
Evidence.
September 20, 2017
Weiner J, Bao Y, Meisel Z. LDI/CHERISH Issue Brief. June 2017.
https://psnet.ahrq.gov/issue/prescription-drug-monitoring-programs-evolution-and-evidence
Health care has been exploring a variety of strategies to mitigate the opioid ep…
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psnet.ahrq.gov/node/855438/psn-pdf
November 15, 2023 - Intravenous (IV) push medications – bridging the gap
between education and clinical practice.
November 15, 2023
ISMP Medication Safety Alert! Acute Care. November 2, 2023;28(22):1-4.
https://psnet.ahrq.gov/issue/intravenous-iv-push-medications-bridging-gap-between-education-and-clinical-
practice
Intravenous…
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psnet.ahrq.gov/node/46801/psn-pdf
July 22, 2019 - Promising roles for pharmacists in addressing the U.S.
opioid crisis.
July 22, 2019
Compton WM, Jones CM, Stein JB, et al. Promising roles for pharmacists in addressing the U.S. opioid
crisis. Res Social Adm Pharm. 2019;15(8):910-916. doi:10.1016/j.sapharm.2017.12.009.
https://psnet.ahrq.gov/issue/promising-roles-…
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psnet.ahrq.gov/node/43990/psn-pdf
April 22, 2015 - Fix and forget or fix and report: a qualitative study of
tensions at the front line of incident reporting.
April 22, 2015
Hewitt TA, Chreim S. Fix and forget or fix and report: a qualitative study of tensions at the front line of
incident reporting. BMJ Qual Saf. 2015;24(5):303-10. doi:10.1136/bmjqs-2014-003279.
h…
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psnet.ahrq.gov/node/37761/psn-pdf
May 14, 2008 - Student perceptions of medical errors: incorporating an
explicit professionalism curriculum in the third-year
surgery clerkship.
May 14, 2008
Newell P, Harris S, Aufses A, et al. Student perceptions of medical errors: incorporating an explicit
professionalism curriculum in the third-year surgery clerkship. J Surg …