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psnet.ahrq.gov/node/43761/psn-pdf
July 01, 2016 - An electronic checklist improves transfer and retention of
critical information at intraoperative handoff of care.
July 1, 2016
Agarwala A, Firth PG, Albrecht MA, et al. An electronic checklist improves transfer and retention of critical
information at intraoperative handoff of care. Anesth Analg. 2015;120(1):96-10…
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psnet.ahrq.gov/node/44574/psn-pdf
October 21, 2015 - Patient safety and quality improvement: reducing risk of
harm.
October 21, 2015
Leonard M. Patient Safety and Quality Improvement: Reducing Risk of Harm. Pediatr Rev.
2015;36(10):448-56; quiz 457-8. doi:10.1542/pir.36-10-448.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-reducing-risk-harm
T…
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psnet.ahrq.gov/node/47260/psn-pdf
August 08, 2018 - Building the Case for Health Literacy: Proceedings of a
Workshop.
August 8, 2018
National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press;
2018. ISBN: 9780309474290.
https://psnet.ahrq.gov/issue/building-case-health-literacy-proceedings-workshop
Health literacy affects p…
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psnet.ahrq.gov/node/43150/psn-pdf
April 30, 2014 - Children's Hospital investigated five patient deaths from
deadly fungal disease in 2009.
April 30, 2014
Duffy J, Harris J, Gade L, et al. Mucormycosis outbreak associated with hospital linens. The Pediatric
infectious disease journal. 2014;33(5):472-6. doi:10.1097/INF.0000000000000261.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/40790/psn-pdf
January 01, 2012 - Nurses' perceptions of simulation-based interprofessional
training program for rapid response and code blue
events.
December 1, 2011
Wehbe-Janek H, Lenzmeier CR, Ogden PE, et al. Nurses' perceptions of simulation-based
interprofessional training program for rapid response and code blue events. J Nurs Care Qual.
2…
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psnet.ahrq.gov/node/47289/psn-pdf
October 24, 2018 - ASHP guidelines on managing drug product shortages.
October 24, 2018
Fox ER, McLaughlin MM. ASHP guidelines on managing drug product shortages. Am J Health Syst Pharm.
2018;75(21):1742-1750. doi:10.2146/ajhp180441.
https://psnet.ahrq.gov/issue/ashp-guidelines-managing-drug-product-shortages
Drug shortages are a pe…
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psnet.ahrq.gov/node/44221/psn-pdf
September 27, 2016 - Reducing surgical errors: implementing a three-hinge
approach to success.
September 27, 2016
Landers R. Reducing surgical errors: implementing a three-hinge approach to success. AORN J.
2015;101(6):657-65. doi:10.1016/j.aorn.2015.04.013.
https://psnet.ahrq.gov/issue/reducing-surgical-errors-implementing-three-hing…
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psnet.ahrq.gov/node/43220/psn-pdf
April 03, 2017 - Patient safety teams recognised at BMJ awards.
April 3, 2017
Gulland A. Berwick Patient Safety Team: making the NHS a safer place. BMJ. 2014;348(mar28 1).
doi:10.1136/bmj.g2404.
https://psnet.ahrq.gov/issue/patient-safety-teams-recognised-bmj-awards
The Great Ormond Street Hospital Foundation NHS Trust received th…
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psnet.ahrq.gov/node/46240/psn-pdf
June 21, 2017 - Implementation of a modified bedside handoff for a
postpartum unit.
June 21, 2017
Wollenhaup CA, Stevenson EL, Thompson J, et al. Implementation of a Modified Bedside Handoff for a
Postpartum Unit. J Nurs Admin. 2017;47(6):320-326. doi:10.1097/NNA.0000000000000487.
https://psnet.ahrq.gov/issue/implementation-modif…
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psnet.ahrq.gov/node/72761/psn-pdf
February 17, 2021 - Using ventilator splitters during the COVID-19 pandemic--
letter to health care providers.
February 17, 2021
Silver Spring, MD: Division of Industry and Consumer Education, US Food and Drug Administration;
February 9. 2021.
https://psnet.ahrq.gov/issue/using-ventilator-splitters-during-covid-19-pandemic-letter-hea…
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psnet.ahrq.gov/node/42872/psn-pdf
December 30, 2014 - Errors in after-hours phone consultations: a simulation
study.
December 30, 2014
Joffe E, Turley JP, Hwang KO, et al. Errors in after-hours phone consultations: a simulation study. BMJ
Qual Saf. 2014;23(5):398-405. doi:10.1136/bmjqs-2013-002243.
https://psnet.ahrq.gov/issue/errors-after-hours-phone-consultations-s…
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psnet.ahrq.gov/node/43231/psn-pdf
July 28, 2014 - Disclosure of adverse events and errors in surgical care:
challenges and strategies for improvement.
July 28, 2014
Lipira LE, Gallagher TH. Disclosure of adverse events and errors in surgical care: challenges and
strategies for improvement. World J Surg. 2014;38(7):1614-21. doi:10.1007/s00268-014-2564-5.
https://p…
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psnet.ahrq.gov/node/42105/psn-pdf
June 28, 2013 - Public perceptions and preferences for patient
notification after an unsafe injection.
June 28, 2013
Schneider AK, Brinsley-Rainisch KJ, Schaefer MK, et al. Public perceptions and preferences for patient
notification after an unsafe injection. J Patient Saf. 2013;9(1):8-12. doi:10.1097/PTS.0b013e318269992d.
https:…
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psnet.ahrq.gov/node/44955/psn-pdf
May 21, 2016 - Accuracy of the Safer Dx Instrument to identify diagnostic
errors in primary care.
May 21, 2016
Al-Mutairi A, Meyer AND, Thomas EJ, et al. Accuracy of the Safer Dx Instrument to Identify Diagnostic
Errors in Primary Care. J Gen Intern Care. 2016;31(6):602-608. doi:10.1007/s11606-016-3601-x.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/42277/psn-pdf
July 02, 2014 - Improving the quality of the surgical morbidity and
mortality conference: a prospective intervention study.
July 2, 2014
Mitchell EL, Lee DY, Arora S, et al. Improving the quality of the surgical morbidity and mortality conference:
a prospective intervention study. Acad Med. 2013;88(6):824-30. doi:10.1097/ACM.0b013…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-5.html
June 01, 2021 - Leadership To Improve Diagnosis: A Call to Action
A Path Forward for Diagnostic Safety Improvement Leadership
Previous Page Next Page
Table of Contents
Leadership To Improve Diagnosis: A Call to Action
Diagnostic Safety as a Challenge for Healthcare Leadership
Why Are Leaders Essential to Diagno…
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psnet.ahrq.gov/node/41188/psn-pdf
March 07, 2012 - Quality improvement and patient care checklists in
intrahospital transfers involving pediatric surgery
patients.
March 7, 2012
Nakayama DK, Lester SS, Rich DR, et al. Quality improvement and patient care checklists in intrahospital
transfers involving pediatric surgery patients. J Pediatr Surg. 2012;47(1):112-8.
…
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psnet.ahrq.gov/node/853249/psn-pdf
September 06, 2023 - How does robotic-assisted surgery change OR safety
culture?
September 6, 2023
How does robotic-assisted surgery change OR safety culture? AMA J Ethics. 2023;25(8):E615-E623.
doi:10.1001/amajethics.2023.615.
https://psnet.ahrq.gov/issue/how-does-robotic-assisted-surgery-change-or-safety-culture
The safety culture …
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psnet.ahrq.gov/node/43610/psn-pdf
October 15, 2014 - Preventing medication errors in neonatology: is it a
dream?
October 15, 2014
Antonucci R, Porcella A. Preventing medication errors in neonatology: Is it a dream? World J Clin Pediatr.
2014;3(3):37-44. doi:10.5409/wjcp.v3.i3.37.
https://psnet.ahrq.gov/issue/preventing-medication-errors-neonatology-it-dream
Discuss…
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psnet.ahrq.gov/node/46427/psn-pdf
April 04, 2018 - Improving Diagnosis in Radiology—Progress and
Proposals.
April 4, 2018
Bruno MA, Johnson K, Argy N, Graber ML, eds. Diagnosis. 2017;4(3):111-191.
https://psnet.ahrq.gov/issue/improving-diagnosis-radiology-progress-and-proposals
Radiology plays a unique role in the determination of a diagnosis. Cognitive and system…