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psnet.ahrq.gov/node/47729/psn-pdf
April 10, 2019 - Reclaiming the systems approach to paediatric safety.
April 10, 2019
Cheung R, Roland D, Lachman P. Reclaiming the systems approach to paediatric safety. Arch Dis Child.
2019;104(12):1130-1133. doi:10.1136/archdischild-2018-316401.
https://psnet.ahrq.gov/issue/reclaiming-systems-approach-paediatric-safety
Children…
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psnet.ahrq.gov/node/864377/psn-pdf
March 13, 2024 - Patients' experiences of dental diagnostic failures: a
qualitative study using social media.
March 13, 2024
Obadan-Udoh E, Howard R, Valmadrid LC, et al. Patients' experiences of dental diagnostic failures: a
qualitative study using social media. J Patient Saf. 2024;20(3):177-185.
doi:10.1097/pts.0000000000001198.…
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psnet.ahrq.gov/node/73530/psn-pdf
July 28, 2021 - The nature, severity and causes of medication incidents
from an Australian community pharmacy incident
reporting system: the QUMwatch study.
July 28, 2021
Adie K, Fois RA, McLachlan AJ, et al. The nature, severity and causes of medication incidents from an
Australian community pharmacy incident reporting system: T…
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psnet.ahrq.gov/node/865593/psn-pdf
April 17, 2024 - An integrative systematic review of promoting patient
safety within prehospital emergency medical services by
paramedics: a role theory perspective.
April 17, 2024
Strandås M, Vizcaya-Moreno M, Ingstad K, et al. An integrative systematic review of promoting patient
safety within prehospital emergency medical servi…
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psnet.ahrq.gov/node/74235/psn-pdf
January 12, 2022 - Where trust flourishes: perceptions of clinicians who
trust their organizations and are trusted by their patients.
January 12, 2022
Linzer M, Neprash HT, Brown RL, et al. Where trust flourishes: perceptions of clinicians who trust their
organizations and are trusted by their patients. Ann Fam Med. 2021;19(6):521-52…
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psnet.ahrq.gov/node/857456/psn-pdf
December 06, 2023 - When mistakes multiply: how inadequate responses to
medical mishaps erode trust in American medicine.
December 6, 2023
Schlesinger M, Grob R. When mistakes multiply: how inadequate responses to medical mishaps erode
trust in American medicine. Hastings Cent Rep. 2023;53(S2):s22-s32. doi:10.1002/hast.1520.
https://…
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psnet.ahrq.gov/node/42626/psn-pdf
October 02, 2013 - Improving patient safety in the ICU by prospective
identification of missing safety barriers using the Bow-Tie
prospective risk analysis model.
October 2, 2013
Kerckhoffs MC, van der Sluijs AF, Binnekade JM, et al. Improving Patient Safety in the ICU by Prospective
Identification of Missing Safety Barriers Using t…
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psnet.ahrq.gov/node/50706/psn-pdf
December 04, 2019 - Improving end-of-rotation transitions of care among ICU
patients
December 4, 2019
Denson JL, Knoeckel J, Kjerengtroen S, et al. Improving end-of-rotation transitions of care among ICU
patients. BMJ Qual Saf. 2019;29(3):250-259. doi:10.1136/bmjqs-2019-009867.
https://psnet.ahrq.gov/issue/improving-end-rotation-tran…
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psnet.ahrq.gov/node/43780/psn-pdf
September 09, 2015 - Rapid response systems and collective (in)competence:
an exploratory analysis of intraprofessional and
interprofessional activation factors.
September 9, 2015
Kitto S, Marshall SD, McMillan SE, et al. Rapid response systems and collective (in)competence: An
exploratory analysis of intraprofessional and interprofes…
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psnet.ahrq.gov/node/44950/psn-pdf
March 02, 2016 - Providers contextualise care more often when they
discover patient context by asking: meta-analysis of three
primary data sets.
March 2, 2016
Schwartz A, Weiner SJ, Binns-Calvey A, et al. Providers contextualise care more often when they discover
patient context by asking: meta-analysis of three primary data sets.…
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psnet.ahrq.gov/node/46184/psn-pdf
January 01, 2018 - A prospective risk assessment of informal carers'
medication administration errors within the domiciliary
setting.
December 19, 2017
Parand A, Faiella G, Franklin BD, et al. A prospective risk assessment of informal carers' medication
administration errors within the domiciliary setting. Ergonomics. 2018;61(1):104…
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psnet.ahrq.gov/node/72482/psn-pdf
November 18, 2020 - Real-time debriefing after critical events: exploring the
gap between principle and reality.
November 18, 2020
Arriaga AF, Szyld D, Pian-Smith MCM. Real-time debriefing after critical events: exploring the gap between
principle and reality. Anesthesiol Clin. 2020;38(4):801-820. doi:10.1016/j.anclin.2020.08.003.
ht…
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psnet.ahrq.gov/node/46579/psn-pdf
April 11, 2018 - Electronic medicine can send you test results quickly. But
what if they're scary?
April 11, 2018
Boodman SG. Washington Post. March 26, 2018.
https://psnet.ahrq.gov/issue/electronic-medicine-can-send-you-test-results-quickly-what-if-theyre-scary
Although providing patients with access to physician notes and test r…
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psnet.ahrq.gov/node/844545/psn-pdf
February 15, 2023 - Providers' and patients' perspectives on diagnostic errors
in the acute care setting.
February 15, 2023
Schnock KO, Garber A, Fraser H, et al. Providers' and patients' perspectives on diagnostic errors in the
acute care setting. Jt Comm J Qual Patient Saf. 2023;49(2):89-97. doi:10.1016/j.jcjq.2022.11.009.
https://…
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psnet.ahrq.gov/node/858165/psn-pdf
December 13, 2023 - When public health goes wrong: toward a new concept of
public health error.
December 13, 2023
Bavli I. When public health goes wrong: toward a new concept of public health error. J Law Med Ethics.
2023;51(2):385-402. doi:10.1017/jme.2023.67.
https://psnet.ahrq.gov/issue/when-public-health-goes-wrong-toward-new-con…
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psnet.ahrq.gov/node/838911/psn-pdf
October 26, 2022 - Medication adverse events in the ambulatory setting: a
mixed-methods analysis.
October 26, 2022
Wong J, Lee S-Y, Sarkar U, et al. Medication adverse events in the ambulatory setting: a mixed-methods
analysis. Am J Health Syst Pharm. 2022;79(24):2230-2243. doi:10.1093/ajhp/zxac253.
https://psnet.ahrq.gov/issue/medi…
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psnet.ahrq.gov/node/43703/psn-pdf
December 19, 2014 - Examining the validity of AHRQ's Patient Safety
Indicators (PSIs): is variation in PSI composite score
related to hospital organizational factors?
December 19, 2014
Shin MH, Sullivan JL, Rosen AK, et al. Examining the validity of AHRQ's patient safety indicators (PSIs): is
variation in PSI composite score related …
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psnet.ahrq.gov/node/73863/psn-pdf
September 22, 2021 - Electronic health record interoperability-why
electronically discontinued medications are still
dispensed.
September 22, 2021
Shervani S, Madden W, Gleason LJ. Electronic health record interoperability-why electronically
discontinued medications are still dispensed. JAMA Intern Med. 2021;181(10):1383-1384.
doi:10…
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psnet.ahrq.gov/node/47693/psn-pdf
January 23, 2019 - Solving alarm fatigue with smartphone technology.
January 23, 2019
Short K, Chung YJ. Solving alarm fatigue with smartphone technology. Nursing (Brux). 2019;49(1):52-57.
doi:10.1097/01.NURSE.0000549728.37810.d9.
https://psnet.ahrq.gov/issue/solving-alarm-fatigue-smartphone-technology
Alarm fatigue contributes to d…
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psnet.ahrq.gov/node/865706/psn-pdf
May 01, 2024 - Stigmatizing language, patient demographics, and errors
in the diagnostic process.
May 1, 2024
Brooks KC, Raffel KE, Chia D, et al. Stigmatizing language, patient demographics, and errors in the
diagnostic process. JAMA Intern Med. 2024;184(6):704-706. doi:10.1001/jamainternmed.2024.0705.
https://psnet.ahrq.gov/is…