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psnet.ahrq.gov/issue/tangible-handoff-team-approach-advancing-structured-communication-labor-and-delivery
June 12, 2013 - Commentary
The tangible handoff: a team approach for advancing structured communication in labor and delivery.
Citation Text:
Block M, Ehrenworth JF, Cuce VM, et al. The tangible handoff: a team approach for advancing structured communication in labor and delivery. Jt Comm J Qual Patient…
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psnet.ahrq.gov/issue/strategies-improving-communication-emergency-department-mediums-and-messages-noisy
November 17, 2010 - Commentary
Strategies for improving communication in the emergency department: mediums and messages in a noisy environment.
Citation Text:
Welch SJ, Cheung DS, Apker J, et al. Strategies for improving communication in the emergency department: mediums and messages in a noisy environ…
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psnet.ahrq.gov/issue/leading-clinical-handover-improvement-change-strategy-implement-best-practices-acute-care
May 18, 2022 - Commentary
Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting.
Citation Text:
Clarke CM, Persaud DD. Leading Clinical Handover Improvement. J Patient Saf. 2011;7(1):11-18. doi:10.1097/pts.0b013e31820c98a8.
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psnet.ahrq.gov/issue/cognitive-processes-involved-blame-and-blame-judgments-and-forgiveness-and-forgiveness
August 23, 2017 - Study
Cognitive processes involved in blame and blame-like judgments and in forgiveness and forgiveness-like judgments.
Citation Text:
Mullet E, Rivière S, Sastre MTM. Cognitive processes involved in blame and blame-like judgments and in forgiveness and forgiveness-like judgments. Am J…
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psnet.ahrq.gov/issue/using-ora-explore-relationship-nursing-unit-communication-patient-safety-and-quality-outcomes
December 11, 2008 - Study
Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes.
Citation Text:
Effken JA, Carley KM, Gephart SM, et al. Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes. Int J Me…
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psnet.ahrq.gov/issue/disclosing-medical-errors-prioritising-needs-patients-and-families
November 11, 2020 - Commentary
Disclosing medical errors: prioritising the needs of patients and families.
Citation Text:
Gallagher TH, Hemmelgarn C, Benjamin EM. Disclosing medical errors: prioritising the needs of patients and families. BMJ Qual Saf. 2023;32(10):557-561. doi:10.1136/bmjqs-2022-015880.
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psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
August 01, 2009 - Misplaced Nasogastric Tube Resulting in Aspiration
Citation Text:
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/issue/enhancing-teamwork-communication-and-patient-safety-responsiveness-paediatric-intensive-care
March 10, 2021 - Study
Enhancing teamwork communication and patient safety responsiveness in a paediatric intensive care unit using the daily safety huddle tool.
Citation Text:
Aldawood F, Kazzaz Y, AlShehri A, et al. Enhancing teamwork communication and patient safety responsiveness in a paediatric inte…
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psnet.ahrq.gov/node/46832/psn-pdf
February 07, 2018 - FDA Drug Safety Communication: FDA requires labeling
changes for prescription opioid cough and cold
medicines to limit their use to adults 18 years and older.
February 7, 2018
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 11, 2018.
https://psnet.ahrq.gov/issue/fda-drug-safety-c…
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psnet.ahrq.gov/node/42682/psn-pdf
January 01, 2015 - Review article: improving the hospital clinical handover
between paramedics and emergency department staff in
the deteriorating patient.
November 13, 2013
Dawson S, King L, Grantham H. Review article: Improving the hospital clinical handover between
paramedics and emergency department staff in the deteriorating pa…
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psnet.ahrq.gov/node/46981/psn-pdf
May 04, 2019 - Lessons learned from implementing a principled
approach to resolution following patient harm.
May 4, 2019
Smith KM, Smith LL, (Jack) Gentry JC, et al. Lessons learned from implementing a principled approach to
resolution following patient harm. J Patient Saf Risk Manag. 2018;24(2):83-89.
doi:10.1177/25160435188138…
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psnet.ahrq.gov/node/41725/psn-pdf
January 01, 2013 - Improving patient handovers from hospital to primary
care: a systematic review.
October 3, 2012
Hesselink G, Schoonhoven L, Barach P, et al. Improving patient handovers from hospital to primary care: a
systematic review. Ann Intern Med. 2013;157(6):417. doi:10.7326/0003-4819-157-6-201209180-00006.
https://psnet.ah…
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psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning
December 22, 2018 - SPOTLIGHT CASE
Engaging Seriously Ill Older Patients in Advance Care Planning
Citation Text:
Heyland DK. Engaging Seriously Ill Older Patients in Advance Care Planning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. …
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - Critical Echocardiogram Result Lost to Follow-up
Citation Text:
Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/issue/using-communication-and-teamwork-skills-cats-assessment-measure-health-care-team-performance
July 05, 2013 - Commentary
Using the Communication and Teamwork Skills (CATS) assessment to measure health care team performance.
Citation Text:
Frankel A, Gardner R, Maynard L, et al. Using the Communication and Teamwork Skills (CATS) Assessment to measure health care team performance. Jt Comm J Qual P…
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psnet.ahrq.gov/issue/effects-physical-environments-medical-wards-medication-communication-processes-affecting
November 17, 2021 - Study
The effects of physical environments in medical wards on medication communication processes affecting patient safety.
Citation Text:
Liu W, Manias E, Gerdtz M. The effects of physical environments in medical wards on medication communication processes affecting patient safety. Heal…
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psnet.ahrq.gov/issue/misuse-pediatric-medications-and-parent-physician-communication-interactive-voice-response
May 27, 2011 - Study
Misuse of pediatric medications and parent–physician communication: an interactive voice response intervention.
Citation Text:
Walsh KE, Bacic J, Phillips BD, et al. Misuse of Pediatric Medications and Parent-Physician Communication: An Interactive Voice Response Intervention. J Pa…
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psnet.ahrq.gov/issue/lost-translation-challenges-and-opportunities-physician-physician-communication-during
April 12, 2011 - Study
Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs.
Citation Text:
Solet DJ, Norvell M, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoff…
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psnet.ahrq.gov/issue/transforming-communication-and-safety-culture-intrapartum-care-multi-organization-blueprint
May 21, 2019 - Commentary
Transforming communication and safety culture in intrapartum care: a multi-organization blueprint.
Citation Text:
Lyndon A, Johnson C, Bingham D, et al. Transforming communication and safety culture in intrapartum care: a multi-organization blueprint. Obstet Gynecol. 2015;125(…
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psnet.ahrq.gov/issue/cardinal-health-recalls-argyle-uvc-insertion-tray-due-missing-instructions-use-safety-scalpel
August 20, 2021 - Press Release/Announcement
Cardinal Health recalls Argyle UVC insertion tray due to missing instructions for use for the Safety Scalpel N11.
Citation Text:
Cardinal Health recalls Argyle UVC insertion tray due to missing instructions for use for the Safety Scalpel N11. MedWatch Safety Al…