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psnet.ahrq.gov/node/44220/psn-pdf
June 10, 2015 - Building a Culture of Patient Safety Through Simulation:
An Interprofessional Learning Model.
June 10, 2015
Gallo K, Smith LG, eds. New York, NY: Springer Publishing Company; 2015. ISBN: 9780826169068.
https://psnet.ahrq.gov/issue/building-culture-patient-safety-through-simulation-interprofessional-learning-
model…
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psnet.ahrq.gov/node/848086/psn-pdf
April 26, 2023 - Preventable harm in the Canadian organ donation and
transplantation system: a descriptive study of missed
organ donor identification and referral.
April 26, 2023
Zavalkoff S, O’Donnell S, Lalani J, et al. Preventable harm in the Canadian organ donation and
transplantation system: a descriptive study of missed orga…
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psnet.ahrq.gov/node/867015/psn-pdf
October 23, 2024 - Supporting perioperative safety during a disaster through
clinical crisis education.
October 23, 2024
Kirkman A, Tripp H, Ward L, et al. Supporting perioperative safety during a disaster through clinical crisis
education. AORN J. 2024;120(4):226-237. doi:10.1002/aorn.14217.
https://psnet.ahrq.gov/issue/supporting-…
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psnet.ahrq.gov/node/41607/psn-pdf
January 03, 2017 - Using a risk assessment approach to determine which
factors influence whether partially bilingual physicians
rely on their non-English language skills or call an
interpreter.
January 3, 2017
Maul L, Regenstein M, Andres E, et al. Using a risk assessment approach to determine which factors
influence whether partia…
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psnet.ahrq.gov/node/854988/psn-pdf
November 01, 2023 - Use of design thinking and human factors approach to
improve situation awareness in the pediatric intensive
care unit.
November 1, 2023
Gifford A, Butcher B, Chima RS, et al. Use of design thinking and human factors approach to improve
situation awareness in the pediatric intensive care unit. J Hosp Med. 2023;18(1…
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psnet.ahrq.gov/node/854835/psn-pdf
October 25, 2023 - Improving patient safety by shifting power from health
professionals to patients.
October 25, 2023
BMJ. 2023(383):2219, 2278, 2319, 2331.
https://psnet.ahrq.gov/issue/improving-patient-safety-shifting-power-health-professionals-patients
This compendium of editorials and opinion pieces discuss “Martha’s Rule,” a ne…
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psnet.ahrq.gov/node/866408/psn-pdf
July 31, 2024 - Influences of leadership, organizational culture, and
hierarchy on raising concerns about patient deterioration:
a qualitative study.
July 31, 2024
Vehvilainen E, Charles A, Sainsbury J, et al. Influences of leadership, organizational culture, and hierarchy
on raising concerns about patient deterioration: a qualit…
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psnet.ahrq.gov/node/863760/psn-pdf
March 06, 2024 - Imagining improved interactions: patients' designs to
address implicit bias.
March 6, 2024
Yang C, Coney L, Mohanraj D, et al. AMIA Annu Symp Proc. 2023;2023:774-783.
https://psnet.ahrq.gov/issue/imagining-improved-interactions-patients-designs-address-implicit-bias
Implicit biases can compromise decision making a…
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psnet.ahrq.gov/node/836713/psn-pdf
March 09, 2022 - Benefits of reporting and analyzing nursing students'
near-miss medication incidents.
March 9, 2022
Dennison S, Freeman M, Giannotti N, et al. Benefits of reporting and analyzing nursing students' near-miss
medication incidents. Nurse Educ. 2022;47(4):202-207. doi:10.1097/nne.0000000000001164.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/44430/psn-pdf
October 28, 2015 - The role of dynamic trade-offs in creating safety—a
qualitative study of handover across care boundaries in
emergency care.
October 28, 2015
Sujan M, Spurgeon P, Cooke M. The role of dynamic trade-offs in creating safety—A qualitative study of
handover across care boundaries in emergency care. Reliab Eng Syst Saf.…
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psnet.ahrq.gov/node/46844/psn-pdf
March 07, 2018 - Learning collaboratives: insights and a new taxonomy
from AHRQ's two decades of experience.
March 7, 2018
Nix M, McNamara P, Genevro J, et al. Learning Collaboratives: Insights And A New Taxonomy From
AHRQ's Two Decades Of Experience. Health Aff (Millwood). 2018;37(2):205-212.
doi:10.1377/hlthaff.2017.1144.
https…
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psnet.ahrq.gov/node/45130/psn-pdf
July 18, 2018 - Surgical fires: decreasing incidence relies on continued
prevention efforts.
July 18, 2018
Bruley ME, Arnold TV, Finley E, Deutsch ES, Treadwell JR. PA-PSRS Pa Patient Saf Advis. June 2018;15.
https://psnet.ahrq.gov/issue/surgical-fires-decreasing-incidence-relies-continued-prevention-efforts
Although surgical fir…
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psnet.ahrq.gov/node/846448/psn-pdf
March 22, 2023 - Understanding patient and clinician reported nonroutine
events in ambulatory surgery.
March 22, 2023
Salwei ME, Anders S, Slagle JM, et al. Understanding patient and clinician reported nonroutine events in
ambulatory surgery. J Patient Saf. 2023;19(2):e38-e45. doi:10.1097/pts.0000000000001089.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/46412/psn-pdf
October 11, 2017 - Team-based care: the changing face of cardiothoracic
surgery.
October 11, 2017
Crawford TC, Conte J, Sanchez JA. Team-Based Care: The Changing Face of Cardiothoracic Surgery.
Surg Clin North Am. 2017;97(4):801-810. doi:10.1016/j.suc.2017.03.003.
https://psnet.ahrq.gov/issue/team-based-care-changing-face-cardiothor…
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psnet.ahrq.gov/node/855091/psn-pdf
November 08, 2023 - Handoff tool improves transitions from the operating
room to the neonatal intensive care unit.
November 8, 2023
Gallois JB, Zagory JA, Barkemeyer B, et al. Handoff tool improves transitions from the operating room to
the neonatal intensive care unit. Pediatr Qual Saf. 2023;8(5):e695. doi:10.1097/pq9.000000000000069…
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psnet.ahrq.gov/node/72663/psn-pdf
January 20, 2021 - Nursing home residents with dementia: association
between place of death and patient safety culture.
January 20, 2021
Orth J, Li Y, Simning A, et al. Nursing Home Residents With Dementia: Association Between Place of
Death and Patient Safety Culture. Gerontologist. 2021;61(8):1296-1306. doi:10.1093/geront/gnaa188.
…
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psnet.ahrq.gov/node/41322/psn-pdf
November 27, 2012 - Errors of medical interpretation and their potential clinical
consequences: a comparison of professional versus ad
hoc versus no interpreters.
November 27, 2012
Flores G, Abreu M, Barone CP, et al. Errors of medical interpretation and their potential clinical
consequences: a comparison of professional versus ad ho…
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psnet.ahrq.gov/node/837598/psn-pdf
June 29, 2022 - Visitor behaviors can influence the risk of patient harm:
an analysis of patient safety reports from 92 hospitals.
June 29, 2022
Sanchez C, Taylor M, Jones RM. Visitor behaviors can influence the risk of patient harm: an analysis of
patient safety reports from 92 hospitals. Patient Safety. 2022;4(2):70-79. doi:10.3…
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psnet.ahrq.gov/node/46939/psn-pdf
July 23, 2018 - Underdiagnosis of dementia: an observational study of
patterns in diagnosis and awareness in US older adults.
July 23, 2018
Amjad H, Roth DL, Sheehan OC, et al. Underdiagnosis of Dementia: an Observational Study of Patterns in
Diagnosis and Awareness in US Older Adults. J Gen Intern Med. 2018;33(7):1131-1138.
doi:…
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psnet.ahrq.gov/node/45726/psn-pdf
December 14, 2016 - National Cancer Institute–American Society of Clinical
Oncology Teams in Cancer Care Project.
December 14, 2016
J Oncol Pract. 2016;12(11):955-1194.
https://psnet.ahrq.gov/issue/national-cancer-institute-american-society-clinical-oncology-teams-cancer-
care-project
Team-based care has been adopted in various spec…