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psnet.ahrq.gov/node/38287/psn-pdf
February 06, 2009 - Teamwork and patient safety in dynamic domains of
healthcare: a review of the literature.
February 6, 2009
Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta
Anaesthesiol Scand. 2009;53(2):143-51. doi:10.1111/j.1399-6576.2008.01717.x.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/36180/psn-pdf
September 29, 2010 - Why nurses make medication errors: a simulation study.
September 29, 2010
Kazaoka T, Ohtsuka K, Ueno K, et al. Why nurses make medication errors: a simulation study. Nurse Educ
Today. 2007;27(4):312-7.
https://psnet.ahrq.gov/issue/why-nurses-make-medication-errors-simulation-study
The investigators used a simulate…
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psnet.ahrq.gov/node/41476/psn-pdf
June 20, 2012 - Interdisciplinary team training: five lessons learned.
June 20, 2012
Contratti F, Ng G, Deeb J. Interdisciplinary team training: five lessons learned. Am J Nurs. 2012;112(6):47-
52. doi:10.1097/01.NAJ.0000415127.84605.1f.
https://psnet.ahrq.gov/issue/interdisciplinary-team-training-five-lessons-learned
This commen…
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psnet.ahrq.gov/node/42185/psn-pdf
April 10, 2013 - Improving patient safety in medicine: is the model of
anaesthesia care enough?
April 10, 2013
Haller G. Improving patient safety in medicine: is the model of anaesthesia care enough? Swiss Med Wkly.
2013;143:w13770. doi:10.4414/smw.2013.13770.
https://psnet.ahrq.gov/issue/improving-patient-safety-medicine-model-an…
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psnet.ahrq.gov/node/844558/psn-pdf
January 13, 2024 - On Patient Safety.
January 13, 2024
Tingle J. Br J Nurs. 2001-2024.
https://psnet.ahrq.gov/issue/patient-safety-19
This series of commentaries discusses a wide range of policy, legal, and operational topics related to
patient safety in the British health system, such as artificial intelligence, patient communicati…
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psnet.ahrq.gov/node/46151/psn-pdf
May 24, 2017 - The last person you'd expect to die in childbirth.
May 24, 2017
Martin N, Montagne R. ProPublica and National Public Radio. May 12, 2017.
https://psnet.ahrq.gov/issue/last-person-youd-expect-die-childbirth
Maternal mortality is increasing in the United States. This news article reports on this critical safety probl…
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psnet.ahrq.gov/node/42757/psn-pdf
November 20, 2013 - Clinical ICT Systems in the Victorian Public Health Sector.
November 20, 2013
Doyle J. Melbourne, Australia: Victorian Auditor-General's Office; October 30, 2013.
https://psnet.ahrq.gov/issue/clinical-ict-systems-victorian-public-health-sector
Following the implementation of a large clinical information communicati…
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psnet.ahrq.gov/node/74193/psn-pdf
December 15, 2021 - Input for the TeamSTEPPS Curriculum Updates.
December 15, 2021
Rockville MD, Agency for Healthcare Quality and Research. December 7, 2021.
https://psnet.ahrq.gov/issue/input-teamstepps-curriculum-updates
The TeamSTEPPS program is an established approach for improving teamwork and communication in
health care. This…
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psnet.ahrq.gov/node/39068/psn-pdf
October 28, 2009 - Four patients say Cedars-Sinai did not tell them they had
received a radiation overdose.
October 28, 2009
Zarembo A.
https://psnet.ahrq.gov/issue/four-patients-say-cedars-sinai-did-not-tell-them-they-had-received-radiation-
overdose
This news piece describes communication gaps following a radiation overdose incid…
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psnet.ahrq.gov/web-mm/not-miscarriage
June 01, 2005 - Not a Miscarriage
Citation Text:
Learman LA. Not a Miscarriage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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…
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psnet.ahrq.gov/web-mm/it-safe-be-direct
September 30, 2015 - Is It Safe to Be Direct?
Citation Text:
Kulkarni NS, Williams M. Is It Safe to Be Direct?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/node/49772/psn-pdf
October 01, 2016 - Lapse in Antibiotics Leads to Sepsis
October 1, 2016
Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
The Case
A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal
pain, fevers, and short…
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psnet.ahrq.gov/node/853772/psn-pdf
September 27, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not
Interchangeable
September 27, 2023
Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
The Case
A fourteen-ye…
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psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
August 30, 2023 - Strategies to Improve Organizational Health Literacy.
Citation Text:
Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy.. 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/web-mm/misleading-complaint
December 01, 2009 - Misleading Complaint
Citation Text:
Soni K, Dhaliwal G. Misleading Complaint. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/node/50843/psn-pdf
January 29, 2020 - Incomplete Orders for Hypertonic Saline to Treat
Hyponatremia
January 29, 2020
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet].
2020.
https://psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
The Case
A 54-year-old man was brought t…
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psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
October 30, 2024 - Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates
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February 9, 2021
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psnet.ahrq.gov/node/836791/psn-pdf
August 21, 2024 - TeamSTEPPS for Diagnosis Improvement.
August 21, 2024
TeamSTEPPS for Diagnosis Improvement.
https://psnet.ahrq.gov/issue/teamstepps-diagnosis-improvement
The recognition of diagnosis as a team activity is energizing new diagnostic process initiatives. Building on
the established TeamSTEPPS® principles, this new Te…
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psnet.ahrq.gov/node/44226/psn-pdf
November 03, 2015 - The Patient Survival Handbook.
November 3, 2015
Powell SM, Stone RD. Peachtree City, GA: Synensis; 2015.
https://psnet.ahrq.gov/issue/patient-survival-handbook
Engaging patients in their care is increasingly advocated as a way to improve safety. This book
recommends actions for patients and families to reduce risk…
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psnet.ahrq.gov/node/74766/psn-pdf
June 24, 2024 - Patient handoffs.
June 24, 2024
Arora V, Farnan J. UpToDate. June 24, 2024.
https://psnet.ahrq.gov/issue/patient-handoffs-0
The change of an inpatient’s location or handoffs between teams can fragment care due to communication,
information, and knowledge gaps. This review examines in-patient transition safety issu…