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psnet.ahrq.gov/node/36279/psn-pdf
May 27, 2011 - Evaluation of laboratory monitoring alerts within a
computerized physician order entry system for
medication orders.
May 27, 2011
Palen TE, Raebel MA, Lyons E, et al. Evaluation of laboratory monitoring alerts within a computerized
physician order entry system for medication orders. Am J Manag Care. 2006;12(7):389…
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psnet.ahrq.gov/node/47468/psn-pdf
October 24, 2018 - Procuring Interoperability: Achieving High-Quality,
Connected, and Person-Centered Care.
October 24, 2018
Pronovost P, Johns MME, Palmer S, et al, eds. Washington, DC: National Academy of Medicine; 2018.
ISBN: 9781947103122.
https://psnet.ahrq.gov/issue/procuring-interoperability-achieving-high-quality-connected-a…
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psnet.ahrq.gov/node/851187/psn-pdf
July 05, 2023 - Patient and public co-creation of healthcare safety and
healthcare system resilience: the case of COVID-19.
July 5, 2023
Albutt AK, Ramsey L, Fylan B, et al. Patient and public co?creation of healthcare safety and healthcare
system resilience: the case of COVID?19. Health Expect. 2023;26(4):1467-1477. doi:10.1111/h…
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psnet.ahrq.gov/node/838306/psn-pdf
October 12, 2022 - Developing the Safer Dx Checklist of Ten Safety
Recommendations for Health Care Organizations to
address diagnostic errors.
October 12, 2022
Singh H, Mushtaq U, Marinez A, et al. Developing the Safer Dx Checklist of Ten Safety Recommendations
for Health Care Organizations to Address Diagnostic Errors. Jt Comm J Qu…
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psnet.ahrq.gov/node/39768/psn-pdf
August 18, 2010 - Medical team training and coaching in the veterans health
administration; assessment and impact on the first 32
facilities in the programme.
August 18, 2010
Neily J, Mills PD, Lee P, et al. Medical team training and coaching in the Veterans Health Administration;
assessment and impact on the first 32 facilities in…
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psnet.ahrq.gov/node/43101/psn-pdf
May 30, 2014 - Instituting a culture of professionalism: the establishment
of a Center for Professionalism and Peer Support.
May 30, 2014
Shapiro J, Whittemore A, Tsen LC. Instituting a culture of professionalism: the establishment of a center for
professionalism and peer support. Jt Comm J Qual Patient Saf. 2014;40(4):168-177.
…
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psnet.ahrq.gov/node/839817/psn-pdf
January 01, 2023 - Ethical leadership supports safety voice by increasing
risk perception and reducing ethical ambiguity: evidence
from the COVID-19 pandemic.
November 9, 2022
Cakir MS, Wardman JK, Trautrims A. Ethical leadership supports safety voice by increasing risk perception
and reducing ethical ambiguity: evidence from the CO…
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psnet.ahrq.gov/node/39748/psn-pdf
August 11, 2010 - Information transfer and communication in surgery: a
systematic review.
August 11, 2010
Nagpal K, Vats A, Lamb B, et al. Information transfer and communication in surgery: a systematic review.
Ann Surg. 2010;252(2):225-39. doi:10.1097/SLA.0b013e3181e495c2.
https://psnet.ahrq.gov/issue/information-transfer-and-comm…
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psnet.ahrq.gov/node/61062/psn-pdf
January 01, 2022 - Medication errors in anesthesiology: is it time to train by
example? Vignettes can assess error awareness,
assessment of harm, disclosure, and reporting practices.
October 28, 2020
Duffy CC, Bass GA, Duncan JR, et al. Medication errors in anesthesiology: is it time to train by example?
Vignettes can assess error a…
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psnet.ahrq.gov/node/72752/psn-pdf
February 17, 2021 - Why do healthcare professionals fail to escalate as per
the early warning system (EWS) protocol? A qualitative
evidence synthesis of the barriers and facilitators of
escalation.
February 17, 2021
O’Neill SM, Clyne B, Bell M, et al. Why do healthcare professionals fail to escalate as per the early warning
system (…
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psnet.ahrq.gov/node/40250/psn-pdf
July 09, 2012 - Patient involvement in patient safety: how willing are
patients to participate?
July 9, 2012
Davis R, Sevdalis N, Vincent C. Patient involvement in patient safety: How willing are patients to
participate? BMJ Qual Saf. 2011;20(1):108-114. doi:10.1136/bmjqs.2010.041871.
https://psnet.ahrq.gov/issue/patient-involvem…
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psnet.ahrq.gov/node/46010/psn-pdf
July 12, 2017 - Changing the medical malpractice system to align with
what we know about patient safety and quality
improvement.
July 12, 2017
Sklar DP. Changing the Medical Malpractice System to Align With What We Know About Patient Safety
and Quality Improvement. Acad Med. 2017;92(7):891-894. doi:10.1097/ACM.0000000000001733.
…
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psnet.ahrq.gov/node/865879/psn-pdf
May 15, 2024 - Strategies that facilitate the delivery of exceptionally good
patient care in general practice: a qualitative study with
patients and primary care professionals.
May 15, 2024
O’Malley R, O’Connor P, Lydon S. Strategies that facilitate the delivery of exceptionally good patient care in
general practice: a qualitati…
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psnet.ahrq.gov/node/43694/psn-pdf
November 17, 2015 - Relationships within inpatient physician housestaff teams
and their association with hospitalized patient outcomes.
November 17, 2015
McAllister C, Leykum LK, Lanham H, et al. Relationships within inpatient physician housestaff teams and
their association with hospitalized patient outcomes. J Hosp Med. 2014;9(12):7…
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psnet.ahrq.gov/node/46547/psn-pdf
April 16, 2018 - Hidden curricula, ethics, and professionalism: clinical
learning environments in becoming and being a
physician: a position paper of the American College of
Physicians.
April 16, 2018
Lehmann LS, Sulmasy LS, Desai S, et al. Hidden Curricula, Ethics, and Professionalism: Optimizing
Clinical Learning Environments i…
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psnet.ahrq.gov/node/866081/psn-pdf
June 05, 2024 - "The patient is awake and we need to stay calm":
reconsidering indirect communication in the face of
medical error and professionalism lapses.
June 5, 2024
Taylor T, Columbus L, Banner H, et al. “The patient is awake and we need to stay calm”: reconsidering
indirect communication in the face of medical error and p…
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psnet.ahrq.gov/node/74063/psn-pdf
April 10, 2019 - Structural racism--a 60-year-old black woman with breast
cancer.
April 10, 2019
Pallok K, De Maio F, Ansell DA. Structural racism--a 60-year-old black woman with breast cancer. N Engl J
Med. 2019;380(16):1489-1493. doi:10.1056/nejmp1811499.
https://psnet.ahrq.gov/issue/structural-racism-60-year-old-black-woman-bre…
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psnet.ahrq.gov/node/39729/psn-pdf
September 20, 2011 - Contextual errors and failures in individualizing patient
care: a multicenter study.
September 20, 2011
Weiner SJ, Schwartz A, Weaver FM, et al. Contextual errors and failures in individualizing patient care: a
multicenter study. Ann Intern Med. 2010;153(2):69-75. doi:10.7326/0003-4819-153-2-201007200-00002.
https…
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www.ahrq.gov/sites/default/files/2025-05/fraser-dunagan-report.pdf
January 01, 2025 - Society of Behavioral Medicine Conference, Baltimore, MD, March 2004.
28. … Society of Behavioral Medicine Conference, Baltimore, MD, March 2004.
30.
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www.ahrq.gov/sites/default/files/2024-07/heritage-report.pdf
January 01, 2024 - Journal of Behavioral
Medicine, 15(5): 447-68.
19. Roter, D.L. and J.A. Hall (1992). … 'Behavioral consequences of consumer dissatisfaction with medical
care.'