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5201. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34762/psn-pdf
      March 28, 2005 - Diffusion of Innovations. 5th ed. March 28, 2005 Rogers EM. New York NY: Free Press; 2005. https://psnet.ahrq.gov/issue/diffusion-innovations-5th-ed Those who seek to improve the quality and safety of health care would be well served by a deeper understanding of how innovations spread through systems. Rogers first…

5202. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40104/psn-pdf
      December 22, 2010 - Noise in the operating room—what do we know? A review of the literature. December 22, 2010 Hasfeldt D, Laerkner E, Birkelund R. Noise in the operating room--what do we know? A review of the literature. J Perianesth Nurs. 2010;25(6):380-6. doi:10.1016/j.jopan.2010.10.001. https://psnet.ahrq.gov/issue/noise-operatin…

5203. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60537/psn-pdf
      May 27, 2020 - I can't turn my brain off. May 27, 2020 Hoffman J. New York Times. May 16, 2020. https://psnet.ahrq.gov/issue/i-cant-turn-my-brain Health care worker stress is a known contributor to disruptive behavior, error and clinician suicide.  This story discusses the impact of the COVID-19 pandemic on psychological strain …

5204. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43217/psn-pdf
      May 28, 2014 - Bullying: a hidden threat to patient safety. May 28, 2014 Longo J, Hain D. Bullying: a hidden threat to patient safety. Nephrol Nurs J. 2014;41(2):193-99; quiz 200. https://psnet.ahrq.gov/issue/bullying-hidden-threat-patient-safety This commentary relates how bullying and other disruptive behaviors remain a pervasi…

5205. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39626/psn-pdf
      June 23, 2010 - The Medication Manager: results of a medication at the bedside pilot in a pediatric teaching institution. June 23, 2010 Wagner D, Pasko D, Glenn D, et al. The Medication Manager. J Patient Saf. 2010;6(2). doi:10.1097/pts.0b013e3181cb43b4. https://psnet.ahrq.gov/issue/medication-manager-results-medication-bedside-p…

5206. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867699/psn-pdf
      June 01, 2023 - Toolkit for Improving Surgical Care and Recovery. June 1, 2023 Agency for Healthcare Research and Quality. Toolkit for Improving Surgical Care and Recovery. June 2023. https://psnet.ahrq.gov/issue/toolkit-improving-surgical-care-and-recovery Improving patient experience fosters better communication, trust, and col…

5207. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853443/psn-pdf
      September 13, 2023 - Complications and Errors in Periodontal and Implant Therapy. September 13, 2023 Zucchelli G, Stefanini M, eds. Periodontol 2000. 2023;92(1):1-398. https://psnet.ahrq.gov/issue/complications-and-errors-periodontal-and-implant-therapy Patient safety in dentistry shares common challenges with medicine and t…

5208. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42843/psn-pdf
      January 22, 2014 - Patient safety in the obstetric and gynecologic office setting. January 22, 2014 Keats JP. Patient safety in the obstetric and gynecologic office setting. Obstet Gynecol Clin North Am. 2013;40(4):611-23. doi:10.1016/j.ogc.2013.08.004. https://psnet.ahrq.gov/issue/patient-safety-obstetric-and-gynecologic-office-set…

5209. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40560/psn-pdf
      June 22, 2011 - Medication errors resulting from confusion between risperidone (Risperdal) and ropinirole (Requip). June 22, 2011 MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; June 13, 2011. https://psnet.ahrq.gov/issue/medication-errors-resulting-confusion-between-rispe…

5210. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44550/psn-pdf
      September 30, 2015 - Infections associated with reprocessed flexible bronchoscopes. September 30, 2015 FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; September 17, 2015. https://psnet.ahrq.gov/issue/infections-associated-reprocessed-flexible-bronchoscopes Use of incompletely cleaned medical devices has b…

5211. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41200/psn-pdf
      January 03, 2017 - Implementing a perioperative handoff tool to improve postprocedural patient transfers. January 3, 2017 Petrovic MA, Martinez EA, Aboumatar HJ. Implementing a perioperative handoff tool to improve postprocedural patient transfers. Jt Comm J Qual Patient Saf. 2012;38(3):135-42. https://psnet.ahrq.gov/issue/implement…

5212. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73123/psn-pdf
      April 01, 2020 - Digital Healthcare Research. April 1, 2020 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/digital-healthcare-research An understanding of the impact that digital tools can have on clinical decision making, patient self-care, and health system improvement is still emerging. This website hi…

5213. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43494/psn-pdf
      November 17, 2014 - Read-back improves information transfer in simulated clinical crises. November 17, 2014 Boyd M, Cumin D, Lombard B, et al. Read-back improves information transfer in simulated clinical crises. BMJ Qual Saf. 2014;23(12):989-93. doi:10.1136/bmjqs-2014-003096. https://psnet.ahrq.gov/issue/read-back-improves-informati…

5214. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850935/psn-pdf
      June 21, 2023 - Non–operating room anesthesia challenges. June 21, 2023 Smith MJ. Anesthesiology News. June 6, 2023. https://psnet.ahrq.gov/issue/non-operating-room-anesthesia-challenges The use of office-based anesthesia presents both care improvements and risks for patients and clinical teams. This article summarizes frontline …

5215. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73860/psn-pdf
      September 22, 2021 - A system safety approach to assessing risks in the sepsis treatment process. September 22, 2021 Kaya GK. A system safety approach to assessing risks in the sepsis treatment process. Appl Ergon. 2021;94:103408. doi:10.1016/j.apergo.2021.103408. https://psnet.ahrq.gov/issue/system-safety-approach-assessing-risks-sep…

5216. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853976/psn-pdf
      September 27, 2023 - Disclosure of Medical Errors. September 27, 2023 Irving, TX: American College of Emergency Physicians; 2023. https://psnet.ahrq.gov/issue/disclosure-medical-errors Error disclosure is difficult yet important for patient and clinician psychological healing. This statement provides guidance to address barriers to em…

5217. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40885/psn-pdf
      November 26, 2014 - Hospital do-not-resuscitate orders: why they have failed and how to fix them. November 26, 2014 Yuen JK, Reid C, Fetters MD. Hospital do-not-resuscitate orders: why they have failed and how to fix them. J Gen Intern Med. 2011;26(7):791-7. doi:10.1007/s11606-011-1632-x. https://psnet.ahrq.gov/issue/hospital-do-not-…

5218. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45311/psn-pdf
      May 20, 2019 - The Joint Commission Big Book of Checklists. 2nd Edition. May 20, 2019 Oakbrook Terrance, IL: Joint Commission; 2018. ISBN: 9781635850598. https://psnet.ahrq.gov/issue/joint-commission-big-book-checklists-2nd-edition Checklists are a widely accepted strategy to improve communication and standardize processes to su…

5219. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41916/psn-pdf
      December 12, 2012 - Process indicators of quality clinical pharmacy services during transitions of care. December 12, 2012 Pharmacy AC of C, Kirwin J, Canales AE, et al. Process indicators of quality clinical pharmacy services during transitions of care. Pharmacotherapy. 2012;32(11):e338-e347. doi:10.1002/phar.1214. https://psnet.ahr…

5220. In Conversation With… Kaveh Shojania, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md
      February 26, 2025 - In Conversation With… Kaveh Shojania, MD November 1, 2015  Citation Text: In Conversation With… Kaveh Shojania, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation For…