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psnet.ahrq.gov/node/49491/psn-pdf
September 01, 2005 - than 60% of events.(12) Observation
of teams in the operating room suggest that as many as 30% of communications
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psnet.ahrq.gov/issue/closing-loop-process-evaluation-inpatient-care-team-communication
March 09, 2019 - Study
Closing the loop: a process evaluation of inpatient care team communication.
Citation Text:
Broman KK, Kensinger C, Hart H, et al. Closing the loop: a process evaluation of inpatient care team communication. BMJ Qual Saf. 2017;26(1):30-32. doi:10.1136/bmjqs-2015-004580.
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psnet.ahrq.gov/issue/test-result-communication-primary-care-clinical-and-office-staff-perspectives
November 20, 2015 - Study
Test result communication in primary care: clinical and office staff perspectives.
Citation Text:
Litchfield I, Bentham L, Lilford RJ, et al. Test result communication in primary care: clinical and office staff perspectives. Fam Pract. 2014;31(5):592-7. doi:10.1093/fampra/cmu041.
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psnet.ahrq.gov/issue/patterns-communication-breakdowns-resulting-injury-surgical-patients
March 03, 2011 - Study
Classic
Patterns of communication breakdowns resulting in injury to surgical patients.
Citation Text:
Greenberg CC, Regenbogen SE, Studdert DM, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg. 2007;204…
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psnet.ahrq.gov/node/846158/psn-pdf
March 15, 2023 - Safety risks and workflow implications associated with
nursing-related free-text communication orders.
March 15, 2023
Staes CJ, Yusuf S, Hambly M, et al. Safety risks and workflow implications associated with nursing-related
free-text communication orders. J Am Med Inform Assoc. 2023;30(5):828-837. doi:10.1093/jami…
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psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
June 01, 2005 - Diagnostic Failure: The Growing Deficit
Citation Text:
Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNo…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_facnotes.docx
December 01, 2017 - Communication
SAY:
Communication in health care can be challenging, requiring senders and receivers of communications
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psnet.ahrq.gov/node/42003/psn-pdf
May 10, 2013 - The effects of computerized provider order entry
implementation on communication in intensive care units.
May 10, 2013
Hoonakker P, Carayon P, Walker JM, et al. The effects of Computerized Provider Order Entry
implementation on communication in Intensive Care Units. Int J Med Inform. 2013;82(5):e107-17.
doi:10.101…
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psnet.ahrq.gov/node/41020/psn-pdf
January 04, 2012 - A 'Communication and Patient Safety' training programme
for all healthcare staff: can it make a difference?
January 4, 2012
Lee P, Allen K, Daly M. A ‘Communication and Patient Safety’ training programme for all healthcare staff:
can it make a difference? BMJ Qual Saf. 2011;21(1). doi:10.1136/bmjqs-2011-000297.
ht…
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psnet.ahrq.gov/node/853966/psn-pdf
September 27, 2023 - The delivery of safe and effective test result
communication, management and follow-up.
September 27, 2023
Georgiou A, Li J, Thomas J, et al. The delivery of safe and effective test result communication,
management and follow-up. Public Health Res Pract. 2023;33(3):e3332324. doi:10.17061/phrp3332324.
https://psnet…
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psnet.ahrq.gov/node/47107/psn-pdf
June 20, 2018 - Challenges in communication from referring clinicians to
pathologists in the electronic health record era.
June 20, 2018
Barbieri AL, Fadare O, Fan L, et al. Challenges in Communication from Referring Clinicians to Pathologists
in the Electronic Health Record Era. J Pathol Inform. 2018;9:8. doi:10.4103/jpi.jpi_70_1…
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psnet.ahrq.gov/node/45522/psn-pdf
January 01, 2020 - Is communication improved with the implementation of an
obstetrical version of the World Health Organization safe
surgery checklist?
November 9, 2016
Govindappagari S, Guardado A, Goffman D, et al. Is Communication Improved With the Implementation of
an Obstetrical Version of the World Health Organization Safe Sur…
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psnet.ahrq.gov/node/50417/psn-pdf
September 04, 2019 - Communicating uncertainty: a narrative review and
framework for future research.
September 4, 2019
Simpkin AL, Armstrong KA. Communicating uncertainty: a narrative review and framework for future
research. J Gen Intern Med. 2019;34(11):2586-2591. doi:10.1007/s11606-019-04860-8.
https://psnet.ahrq.gov/issue/communi…
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psnet.ahrq.gov/node/39331/psn-pdf
March 03, 2010 - Meta-analysis: effect of interactive communication
between collaborating primary care physicians and
specialists.
March 3, 2010
Foy R, Hempel S, Rubenstein L, et al. Meta-analysis: effect of interactive communication between
collaborating primary care physicians and specialists. Ann Intern Med. 2010;152(4):247-58.…
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psnet.ahrq.gov/node/72708/psn-pdf
February 03, 2021 - How communication "failed" or "saved the day":
counterfactual accounts of medical errors.
February 3, 2021
Street RL, Petrocelli JV, Amroze A, et al. How Communication “Failed” or “Saved the Day”: Counterfactual
Accounts of Medical Errors. J Patient Exp. 2020;7(6):1247-1254. doi:10.1177/2374373520925270.
https://p…
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psnet.ahrq.gov/node/47252/psn-pdf
August 01, 2018 - Communication errors in radiology—pitfalls and how to
avoid them.
August 1, 2018
Waite S, Scott JM, Drexler I, et al. Communication errors in radiology - Pitfalls and how to avoid them. Clin
Imaging. 2018;51:266-272. doi:10.1016/j.clinimag.2018.05.025.
https://psnet.ahrq.gov/issue/communication-errors-radiology-pi…
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psnet.ahrq.gov/issue/reducing-diagnostic-errors-through-effective-communication-harnessing-power-information
March 10, 2011 - Commentary
Reducing diagnostic errors through effective communication: harnessing the power of information technology.
Citation Text:
Singh H, Naik AD, Rao R, et al. Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology. J Gen Intern…
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psnet.ahrq.gov/issue/theory-based-instrument-evaluate-team-communication-operating-room-balancing-measurement
June 23, 2010 - Commentary
A theory-based instrument to evaluate team communication in the operating room: balancing measurement authenticity and reliability.
Citation Text:
Lingard LA, Regehr G, Espin S, et al. A theory-based instrument to evaluate team communication in the operating room: balancing …
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psnet.ahrq.gov/node/49466/psn-pdf
October 14, 2004 - Hard to Swallow
October 1, 2004
Driver J. Hard to Swallow. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/hard-swallow
The Case
An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic
attack (TIA) and respiratory difficulties. The nurses noted that the patient, …
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psnet.ahrq.gov/node/40515/psn-pdf
June 15, 2011 - Implementing handoff communication.
June 15, 2011
Ardoin KB, Broussard L. Implementing handoff communication. J Nurses Staff Dev. 2011;27(3):128-35.
doi:10.1097/NND.0b013e318217b3dd.
https://psnet.ahrq.gov/issue/implementing-handoff-communication
This commentary describes how one hospital implemented the SBAR tool…