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1921. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41026/psn-pdf
      March 02, 2012 - SBAR: electronic handoff tool for noncomplicated procedural patients. March 2, 2012 Wentworth L, Diggins J, Bartel D, et al. SBAR: electronic handoff tool for noncomplicated procedural patients. J Nurs Care Qual. 2012;27(2):125-31. doi:10.1097/NCQ.0b013e31823cc9a0. https://psnet.ahrq.gov/issue/sbar-electronic-hand…

1922. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46174/psn-pdf
      August 30, 2017 - Inpatients notes: sensemaking—fostering a shared understanding in clinical teams. August 30, 2017 Leykum LK, O'Leary KJ. Web Exclusives. Annals for Hospitalists Inpatient Notes - Sensemaking-Fostering a Shared Understanding in Clinical Teams. Ann Intern Med. 2017;167(4):HO2-HO3. doi:10.7326/M17- 1829. https://psn…

1923. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45951/psn-pdf
      October 31, 2017 - A systematic review of team training in health care: ten questions. October 31, 2017 Marlow SL, Hughes A, Sonesh SC, et al. A Systematic Review of Team Training in Health Care: Ten Questions. Jt Comm J Qual Patient Saf. 2017;43(4):197-204. doi:10.1016/j.jcjq.2016.12.004. https://psnet.ahrq.gov/issue/systematic-rev…

1924. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42049/psn-pdf
      February 20, 2013 - Mitigating error vulnerability at the transition of care through the use of health IT applications. February 20, 2013 Cortelyou-Ward K, Swain A, Yeung T. Mitigating Error Vulnerability at the Transition of Care through the Use of Health IT Applications. J Med Syst. 2012;36(6). doi:10.1007/s10916-012-9855-x. https:…

1925. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50875/psn-pdf
      February 05, 2020 - Implementing Closing the Loop. Safe Practices for Diagnostic Results February 5, 2020 Partnership for HIT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2020. https://psnet.ahrq.gov/issue/implementing-closing-loop-safe-practices-diagnostic-results Health information technology (HIT) can improve record keepi…

1926. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36904/psn-pdf
      April 27, 2010 - What whiteboards in a trauma center operating suite can teach us about emergency department communication. April 27, 2010 Xiao Y, Schenkel SM, Faraj S, et al. What whiteboards in a trauma center operating suite can teach us about emergency department communication. Ann Emerg Med. 2007;50(4):387-95. https://psnet.a…

1927. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41438/psn-pdf
      January 03, 2017 - Implementing SBAR across a large multihospital health system. January 3, 2017 Compton J, Copeland K, Flanders S, et al. Implementing SBAR across a large multihospital health system. Jt Comm J Qual Patient Saf. 2012;38(6):261-8. https://psnet.ahrq.gov/issue/implementing-sbar-across-large-multihospital-health-system…

1928. Dangerous Shift | PSNet
      psnet.ahrq.gov/web-mm/dangerous-shift
      July 24, 2013 - SPOTLIGHT CASE Dangerous Shift Citation Text: Patterson ES. Dangerous Shift. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…

1929. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49519/psn-pdf
      September 01, 2006 - Triple Handoff September 1, 2006 Vidyarthi A. Triple Handoff. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/triple-handoff Case Objectives Appreciate the prevalence of handoffs and sign out related errors. Understand the key elements of a safe and effective written and verbal sign out. List Kotter’s 8 st…

1930. Mistaken Identity | PSNet
      psnet.ahrq.gov/web-mm/mistaken-identity
      December 18, 2014 - Mistaken Identity Citation Text: Hall LW. Mistaken Identity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

1931. Adverse Event During Intrahospital Transport | PSNet
      psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
      June 16, 2021 - Adverse Event During Intrahospital Transport Citation Text: Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar …

1932. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk | PSNet
      psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
      January 31, 2024 - Best practices for communicating after patient safety errors have occurred may include the following:

1933. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45372/psn-pdf
      November 18, 2016 - Determinants of patient–oncologist prognostic discordance in advanced cancer. November 18, 2016 Gramling R, Fiscella K, Xing G, et al. Determinants of Patient-Oncologist Prognostic Discordance in Advanced Cancer. JAMA Oncol. 2016;2(11):1421-1426. doi:10.1001/jamaoncol.2016.1861. https://psnet.ahrq.gov/issue/determ…

1934. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/839814/psn-pdf
      January 01, 2023 - Influencing a culture of quality and safety through huddles. November 9, 2022 McCain N, Ferguson T, Barry Hultquist T, et al. Influencing a culture of quality and safety through huddles. J Nurs Care Qual. 2023;38(1):26-32. doi:10.1097/ncq.0000000000000642. https://psnet.ahrq.gov/issue/influencing-culture-quality-a…

1935. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39603/psn-pdf
      February 16, 2011 - The Schwartz Center Rounds: evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, and provider support. February 16, 2011 Lown BA, Manning CF. The Schwartz Center Rounds: evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, …

1936. Patient Safety in Primary Care | PSNet
      psnet.ahrq.gov/perspective/patient-safety-primary-care
      January 31, 2020 - Annual Perspective Patient Safety in Primary Care February 21, 2020  View more articles from the same authors. Citation Text: Schiff G, Hall KK, Fitall E. Patient Safety in Primary Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…

1937. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.257_slideshow.ppt
      December 01, 2011 - Spotlight Case July 2008 Spotlight Case Order Interrupted by Text: Multitasking Mishap * * Source and Credits This presentation is based on the December 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: John Halamka, MD, MS, Chief Informa…

1938. Responding to Patient Safety Events | PSNet
      psnet.ahrq.gov/primer/responding-patient-safety-events
      October 18, 2023 - Responding to Patient Safety Events Citation Text: Shaikh U. Responding to Patient Safety Events. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…

1939. Practical challenges of introducing WHO surgical checklist: UK pilot experience. | PSNet
      psnet.ahrq.gov/issue/practical-challenges-introducing-who-surgical-checklist-uk-pilot-experience
      September 26, 2012 - Study Practical challenges of introducing WHO surgical checklist: UK pilot experience. Citation Text: Vats A, Vincent CA, Nagpal K, et al. Practical challenges of introducing WHO surgical checklist: UK pilot experience. BMJ. 2010;340(jan13 2). doi:10.1136/bmj.b5433. Copy Citation …

1940. Meta-analyses of the effects of standardized handoff protocols on patient, provider, and organizational outcomes. | PSNet
      psnet.ahrq.gov/issue/meta-analyses-effects-standardized-handoff-protocols-patient-provider-and-organizational
      June 01, 2022 - Review Meta-analyses of the effects of standardized handoff protocols on patient, provider, and organizational outcomes. Citation Text: Keebler JR, Lazzara EH, Patzer BS, et al. Meta-Analyses of the Effects of Standardized Handoff Protocols on Patient, Provider, and Organizational Outcom…