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psnet.ahrq.gov/node/60796/psn-pdf
August 12, 2020 - The challenges and opportunities for shared decision
making highlighted by COVID-19.
August 12, 2020
Abrams EM, Shaker M, Oppenheimer J, et al. The challenges and opportunities for shared decision making
highlighted by COVID-19. J Allergy Clin Immunol Pract. 2020;8(8):2474-2480.e1.
doi:10.1016/j.jaip.2020.07.003.
…
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psnet.ahrq.gov/node/855105/psn-pdf
January 01, 2024 - Sentinel Event Alert 68: updated surgical fire prevention
for the 21st Century.
November 8, 2023
Sentinel Event Alert 68: Updated Surgical Fire Prevention for the 21st Century. Jt Comm J Qual Patient
Saf. 2024;50(2):157-160. doi:10.1016/j.jcjq.2023.10.003.
https://psnet.ahrq.gov/issue/sentinel-event-alert-68-updat…
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psnet.ahrq.gov/node/47299/psn-pdf
March 20, 2019 - Unintentionally retained guidewires: a descriptive study
of 73 sentinel events.
March 20, 2019
Steelman VM, Thenuwara K, Shaw C, et al. Unintentionally Retained Guidewires: A Descriptive Study of 73
Sentinel Events. Jt Comm J Qual Saf. 2019;45(2):81-90. doi:10.1016/j.jcjq.2018.08.003.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/36189/psn-pdf
February 15, 2010 - Identification errors involving clinical laboratories: a
College of American Pathologists Q-Probes study of
patient and specimen identification errors at 120
institutions.
February 15, 2010
Pathologists C of A, Valenstein PN, Raab SS, et al. Identification errors involving clinical laboratories: a
College of Amer…
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psnet.ahrq.gov/node/43789/psn-pdf
August 05, 2015 - Do cell phones belong in the operating room?
August 5, 2015
Luthra S. Kaiser Health News. July 14, 2015.
https://psnet.ahrq.gov/issue/do-cell-phones-belong-operating-room
Distractions can lead to care and process omissions. Reporting on the prevalence of mobile technology in
the operating room and how it can hinde…
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psnet.ahrq.gov/node/60205/psn-pdf
April 08, 2020 - How should U.S. hospitals prepare for Coronavirus
disease 2019 (COVID-19)?
April 8, 2020
Chopra V, Toner E, Waldhorn R, et al. How Should U.S. Hospitals Prepare for Coronavirus Disease 2019
(COVID-19)? Ann Intern Med. 2020;172(9):621-622. doi:10.7326/m20-0907.
https://psnet.ahrq.gov/issue/how-should-us-hospitals-p…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/worksheet.docx
May 01, 2017 - AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership
AHRQ Safety Program for Perinatal Care
Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership
Purpose: To enhance communication and shared problem solving between clinic…
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psnet.ahrq.gov/node/39887/psn-pdf
September 29, 2010 - High-alert medications: shared accountability for risk
identification and error prevention.
September 29, 2010
Paparella S. High-alert medications: shared accountability for risk identification and error prevention.
Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Associat…
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psnet.ahrq.gov/node/43189/psn-pdf
December 15, 2014 - Twitter as a tool to enhance student engagement during
an interprofessional patient safety course.
December 15, 2014
Mckay M, Sanko JS, Shekhter I, et al. Twitter as a tool to enhance student engagement during an
interprofessional patient safety course. J Interprof Care. 2014;28(6):565-7.
doi:10.3109/13561820.2014…
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psnet.ahrq.gov/node/44385/psn-pdf
October 13, 2015 - Same-hospital readmission rates as a measure of
pediatric quality of care.
October 13, 2015
Khan A, Nakamura MM, Zaslavsky AM, et al. Same-Hospital Readmission Rates as a Measure of Pediatric
Quality of Care. JAMA Pediatr. 2015;169(10):905-12. doi:10.1001/jamapediatrics.2015.1129.
https://psnet.ahrq.gov/issue/same…
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psnet.ahrq.gov/node/42839/psn-pdf
January 09, 2014 - Teaching medical error disclosure to residents using
patient-centered simulation training.
January 9, 2014
Sukalich S, Elliott JO, Ruffner G. Teaching medical error disclosure to residents using patient-centered
simulation training. Acad Med. 2014;89(1):136-43. doi:10.1097/ACM.0000000000000046.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/45711/psn-pdf
March 27, 2017 - Management of a patient with a latex allergy.
March 27, 2017
Minami CA, Barnard C, Bilimoria KY. Management of a Patient With a Latex Allergy. JAMA.
2017;317(3):309-310. doi:10.1001/jama.2016.20034.
https://psnet.ahrq.gov/issue/management-patient-latex-allergy
This case analysis discusses the use of a latex cathet…
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psnet.ahrq.gov/node/50382/psn-pdf
September 25, 2019 - The FIRST curriculum: cultivating speaking up behaviors
in the Clinical Learning Environment.
September 25, 2019
Best JA, Kim S. The FIRST Curriculum: Cultivating Speaking Up Behaviors in the Clinical Learning
Environment. J Contin Educ Nurs. 2019;50(8):355-361. doi:10.3928/00220124-20190717-06.
https://psnet.ahrq…
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psnet.ahrq.gov/node/47462/psn-pdf
October 31, 2018 - Emergency department checklist: an innovation to
improve safety in emergency care.
October 31, 2018
Redfern E, Hoskins R, Gray J, et al. Emergency department checklist: an innovation to improve safety in
emergency care. BMJ Open Qual. 2018;7(3):e000325. doi:10.1136/bmjoq-2018-000325.
https://psnet.ahrq.gov/issue/e…
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psnet.ahrq.gov/node/42248/psn-pdf
June 12, 2013 - Measuring handoff quality in labor and delivery:
development, validation, and application of the
Coordination of Handoff Effectiveness Questionnaire
(CHEQ).
June 12, 2013
Block M, Ehrenworth JF, Cuce VM, et al. Measuring handoff quality in labor and delivery: development,
validation, and application of the Coordi…
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psnet.ahrq.gov/node/854252/psn-pdf
October 04, 2023 - Standardization and visualization of the surgical time-out.
October 4, 2023
Levy BE, Wilt WS, Lantz S, et al. Standardization and visualization of the surgical time-out. J Patient Saf.
2023;19(7):453-459. doi:10.1097/pts.0000000000001156.
https://psnet.ahrq.gov/issue/standardization-and-visualization-surgical-time-…
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psnet.ahrq.gov/node/43768/psn-pdf
December 10, 2014 - Accountability in nursing practice: why it is important for
patient safety.
December 10, 2014
Battié R, Steelman VM. Accountability in nursing practice: why it is important for patient safety. AORN J.
2014;100(5):537-541. doi:10.1016/j.aorn.2014.08.008.
https://psnet.ahrq.gov/issue/accountability-nursing-practice-…
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psnet.ahrq.gov/node/74244/psn-pdf
May 30, 2019 - Racial and ethnic differences in the experience and
treatment of noncancer pain.
May 30, 2019
Meints SM, Cortes A, Morais CA, et al. Racial and ethnic differences in the experience and treatment of
noncancer pain. Pain Manag. 2019;9(3):317-334. doi:10.2217/pmt-2018-0030.
https://psnet.ahrq.gov/issue/racial-and-eth…
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psnet.ahrq.gov/node/46628/psn-pdf
December 18, 2017 - Residency evaluations—where is the patient voice?
December 18, 2017
Tummalapalli SL. Residency Evaluations-Where Is the Patient Voice? JAMA Intern Med.
2017;177(12):1722-1723. doi:10.1001/jamainternmed.2017.6029.
https://psnet.ahrq.gov/issue/residency-evaluations-where-patient-voice
Residents rarely receive feedba…
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psnet.ahrq.gov/node/60555/psn-pdf
January 01, 2021 - Putting the patient in patient safety investigations:
barriers and strategies for involvement.
June 3, 2020
Busch IM, Saxena A, Wu AW. Putting the patient in patient safety investigations: barriers and strategies for
involvement. J Patient Saf. 2021;17(5):358-362. doi:10.1097/pts.0000000000000699.
https://psnet.ah…