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2521. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35394/psn-pdf
      April 06, 2011 - Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. April 6, 2011 Lingard L, Espin S, Rubin B, et al. Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual Sa…

2522. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60534/psn-pdf
      May 27, 2020 - Hospital workers complain of minimal disclosure after COVID exposures. May 27, 2020 Gold J, Hawryluk M. Kaiser Health News. May 13, 2020. https://psnet.ahrq.gov/issue/hospital-workers-complain-minimal-disclosure-after-covid-exposures A successful safety culture is consistently evident across all areas of a hospita…

2523. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43391/psn-pdf
      July 30, 2014 - Special Issue on Patient Safety. July 30, 2014 West J Nurs Res. 2014;36(7):851-946. https://psnet.ahrq.gov/issue/special-issue-patient-safety-0 Articles in this special issue discuss errors of omission in nursing, the importance of situational awareness during medication administration, how complexity of health ca…

2524. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42511/psn-pdf
      February 06, 2014 - Ending disruptive behavior: staff nurse recommendations to nurse educators. February 6, 2014 Lux KM, Hutcheson JB, Peden AR. Ending disruptive behavior: staff nurse recommendations to nurse educators. Nurse Educ Pract. 2014;14(1):37-42. doi:10.1016/j.nepr.2013.06.014. https://psnet.ahrq.gov/issue/ending-disruptive…

2525. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44263/psn-pdf
      November 06, 2015 - Delivering the right diet to the right patient every time. November 6, 2015 Wallace SC. PA-PSRS Patient Saf Advis. 2015;12:62-70. https://psnet.ahrq.gov/issue/delivering-right-diet-right-patient-every-time This article analyzed data on dietary errors submitted to a state reporting program and found that more than …

2526. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60215/psn-pdf
      April 08, 2020 - Pain Alleviation Toolkit. April 8, 2020 American Society of Anesthesiologists, American Academy of Orthopaedic Surgeons. March 12, 2020. https://psnet.ahrq.gov/issue/pain-alleviation-toolkit Communication and shared decision-making are fundamental tactics to guide clinical team and patient efforts to minimize the …

2527. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44636/psn-pdf
      November 04, 2015 - The most crucial half-hour at a hospital: the shift change. November 4, 2015 Landro L. https://psnet.ahrq.gov/issue/most-crucial-half-hour-hospital-shift-change Information exchange can be challenging when nurses hand off care responsibilities at the end of their shifts. This news article discusses bedside shift r…

2528. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46198/psn-pdf
      August 16, 2017 - Challenging authority during an emergency—the effect of a teaching intervention. August 16, 2017 Friedman Z, Perelman V, McLuckie D, et al. Challenging Authority During an Emergency-the Effect of a Teaching Intervention. Crit Care Med. 2017;45(8):e814-e820. doi:10.1097/CCM.0000000000002450. https://psnet.ahrq.gov/…

2529. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40184/psn-pdf
      December 29, 2014 - Non-emergency patient transport: what are the quality and safety issues? A systematic review. December 29, 2014 Hains IM, Marks A, Georgiou A, et al. Non-emergency patient transport: what are the quality and safety issues? A systematic review. Int J Qual Health Care. 2011;23(1):68-75. doi:10.1093/intqhc/mzq076. ht…

2530. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39749/psn-pdf
      August 11, 2010 - An evaluation of information transfer through the continuum of surgical care: a feasibility study. August 11, 2010 Nagpal K, Vats A, Ahmed K, et al. An evaluation of information transfer through the continuum of surgical care: a feasibility study. Ann Surg. 2010;252(2):402-7. doi:10.1097/SLA.0b013e3181e986df. http…

2531. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38200/psn-pdf
      November 05, 2008 - Measuring mobile patient safety information system success: an empirical study. November 5, 2008 Jen W-Y, Chao C-C. Measuring mobile patient safety information system success: an empirical study. Int J Med Inform. 2008;77(10):689-97. doi:10.1016/j.ijmedinf.2008.03.003. https://psnet.ahrq.gov/issue/measuring-mobile…

2532. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37349/psn-pdf
      January 06, 2012 - Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. January 6, 2012 Wiegmann DA, Elbardissi AW, Dearani JA, et al. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery. 2007;142(5):658-65. https://psnet.ahrq.…

2533. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/858324/psn-pdf
      December 13, 2023 - Many people of color worry good health care is tied to their appearance. December 13, 2023 DeGuzman C. KFF Health News. December 5, 2023 https://psnet.ahrq.gov/issue/many-people-color-worry-good-health-care-tied-their-appearance Racial and ethnic bias permeates medical interactions to detract from safe and effecti…

2534. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41822/psn-pdf
      November 07, 2012 - A case of adverse drug reaction induced by dispensing error. November 7, 2012 Gallelli L, Staltari O, Palleria C, et al. A case of adverse drug reaction induced by dispensing error. J Forensic Leg Med. 2012;19(8):497-8. doi:10.1016/j.jflm.2012.04.026. https://psnet.ahrq.gov/issue/case-adverse-drug-reaction-induced…

2535. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50784/psn-pdf
      January 08, 2020 - Improving Quality of Care and Patient Outcomes During Care Transitions (R01). January 8, 2020 Rockville, MD: Agency for Healthcare Research and Quality; December 6, 2019. PA-20-068. https://psnet.ahrq.gov/issue/improving-quality-care-and-patient-outcomes-during-care-transitions-r01 Communication during patient tra…

2536. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43123/psn-pdf
      August 04, 2015 - Redesigning surgical decision making for high-risk patients. August 4, 2015 Glance LG, Osler T, Neuman MD. Redesigning surgical decision making for high-risk patients. N Engl J Med. 2014;370(15):1379-1381. doi:10.1056/NEJMp1315538. https://psnet.ahrq.gov/issue/redesigning-surgical-decision-making-high-risk-patient…

2537. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72865/psn-pdf
      March 17, 2021 - 5 pandemic mistakes we keep repeating. We can learn from our failures. March 17, 2021 Zeynep Tufekci. The Atlantic. February 26, 2021 https://psnet.ahrq.gov/issue/5-pandemic-mistakes-we-keep-repeating-we-can-learn-our-failures Failures in communication have impacts on patients, teams, organizations and society. Th…

2538. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838142/psn-pdf
      September 21, 2022 - A health system that won't learn from its mistakes. September 21, 2022 Keller C. A health system that won't learn from its mistakes. Health Aff (Millwood). 2022;41(9):1353-1356. doi:10.1377/hlthaff.2022.00581. https://psnet.ahrq.gov/issue/health-system-wont-learn-its-mistakes Communication failures due to hierarch…

2539. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43297/psn-pdf
      June 25, 2014 - The limits of checklists: handoff and narrative thinking. June 25, 2014 Hilligoss B, Moffatt-Bruce SD. The limits of checklists: handoff and narrative thinking. BMJ Qual Saf. 2014;23(7):528-33. doi:10.1136/bmjqs-2013-002705. https://psnet.ahrq.gov/issue/limits-checklists-handoff-and-narrative-thinking Communicatio…

2540. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60698/psn-pdf
      July 15, 2020 - Older Adults and COVID-19: Implications for Aging Policy and Practice. July 15, 2020 Miller EA, ed. J Aging Soc Policy. 2020;32(4-5):297-535. https://psnet.ahrq.gov/issue/older-adults-and-covid-19-implications-aging-policy-and-practice The COVID-19 crisis has disproportionally impacted the lives of older adul…