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psnet.ahrq.gov/node/854827/psn-pdf
October 25, 2023 - Beyond the surgical safety checklist: using intraoperative
handoff to facilitate team situation awareness in the OR.
October 25, 2023
Ramjaun A, Hammond Mobilio M, Wright N, et al. Beyond the surgical safety checklist: using intraoperative
handoff to facilitate team situation awareness in the OR. Ann Surg. 2023;278…
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psnet.ahrq.gov/node/73257/psn-pdf
December 01, 2021 - Peer Review of a Report on Strategies to Improve Patient
Safety.
May 12, 2021
Washington DC: National Academies of Sciences, Engineering, and Medicine; 2021. ISBN:
9780309462808.
https://psnet.ahrq.gov/issue/peer-review-report-strategies-improve-patient-safety
The Patient Safety and Quality Improvement Act of 200…
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psnet.ahrq.gov/node/47926/psn-pdf
May 22, 2019 - The Canadian Quality and Patient Safety Framework for
Health and Social Services.
May 22, 2019
Canadian Patient Safety Institute and Health Standards Organization.
https://psnet.ahrq.gov/issue/canadian-quality-and-patient-safety-framework-health-and-social-services
This 5-year framework aims to guide the activitie…
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psnet.ahrq.gov/node/50748/psn-pdf
December 18, 2019 - Systematic review of interventions to improve safety and
quality of anticoagulant prescribing for therapeutic
indications for hospital inpatients
December 18, 2019
Frazer A, Rowland J, Mudge A, et al. Eur J Clin Pharmacol. 2019;75(12):1645-1657.
https://psnet.ahrq.gov/issue/systematic-review-interventions-imp…
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psnet.ahrq.gov/node/73501/psn-pdf
July 14, 2021 - Deficiencies in Emergency Preparedness for Veterans
Health Administration Telemental Health Care at VA Clinic
Locations Prior to the Pandemic.
July 14, 2021
Washington, DC: Department of Veterans Affairs, Office of Inspector General. June 24, 2021. Report No.
19-09808-171.
https://psnet.ahrq.gov/issue/deficiencie…
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psnet.ahrq.gov/web-mm/empty-handoff
August 01, 2017 - member ("lollipop man"), who notices, understands, and predicts consequences
Situation awareness
Consultants
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psnet.ahrq.gov/node/33663/psn-pdf
September 15, 2008 - A system-wide
review of obstetrical practices at each hospital was undertaken by the consultants, Drs
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psnet.ahrq.gov/web-mm/communication-failure-whos-charge
April 01, 2018 - weigh the data and move patient care forward by directing and focusing a team of ICU providers and consultants
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psnet.ahrq.gov/web-mm/low-totem-pole
October 01, 2003 - As business consultants like to say, “Culture eats strategy for lunch.”
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psnet.ahrq.gov/node/37118/psn-pdf
October 04, 2011 - Knowledge translation in critical care: factors associated
with prescription of commonly recommended best
practices for critically ill patients.
October 4, 2011
Ilan R, Fowler RA, Geerts R, et al. Knowledge translation in critical care: factors associated with
prescription of commonly recommended best practices fo…
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psnet.ahrq.gov/node/36198/psn-pdf
March 28, 2011 - Using human error theory to explore the supply of non-
prescription medicines from community pharmacies.
March 28, 2011
Watson MC, Bond CM, Johnston M, et al. Using human error theory to explore the supply of non-
prescription medicines from community pharmacies. Qual Saf Health Care. 2006;15(4):244-50.
https://ps…
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psnet.ahrq.gov/node/41107/psn-pdf
May 04, 2012 - A prospective, multicenter study of pharmacist activities
resulting in medication error interception in the
emergency department.
May 4, 2012
Patanwala AE, Sanders AB, Thomas MC, et al. A prospective, multicenter study of pharmacist activities
resulting in medication error interception in the emergency department.…
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psnet.ahrq.gov/node/34661/psn-pdf
March 07, 2005 - Teaching smart people how to learn.
March 7, 2005
Argyris C. Harvard Business Review. 1991:69(May-June):99+.
https://psnet.ahrq.gov/issue/teaching-smart-people-learn
Argyris, a Harvard Business School professor, theorizes that companies and organizations must learn in
order to continually improve and succeed, but …
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psnet.ahrq.gov/node/60543/psn-pdf
May 27, 2020 - Wrong Catheter in the Right Patient
May 27, 2020
Chia C, Molla M. Wrong Catheter in the Right Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
The Case
A 55-year-old man with history of emphysema was admitted to the hospital for pneumonia. The patient had
two?peripheral…
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psnet.ahrq.gov/node/837899/psn-pdf
August 24, 2022 - Feelings of trust and of safety are related facets of the
patient's experience in surgery: a descriptive qualitative
study in 80 patients.
August 24, 2022
Occelli P, Mougeot F, Robelet M, et al. Feelings of trust and of safety are related facets of the patient's
experience in surgery: a descriptive qualitative stu…
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psnet.ahrq.gov/node/73488/psn-pdf
July 14, 2021 - Influences of physical layout and space on patient safety
and communication in ambulatory oncology practices: a
multisite, mixed method investigation.
July 14, 2021
Fauer AJ. Influences of physical layout and space on patient safety and communication in ambulatory
oncology practices: a multisite, mixed method inve…
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psnet.ahrq.gov/node/72710/psn-pdf
February 03, 2021 - A poison information centre can provide important
assessment and guidance regarding medication errors in
nursing homes: a prospective cohort study.
February 3, 2021
Vinther S, Bøgevig S, Eriksen KR, et al. A poison information centre can provide important assessment and
guidance regarding medication errors in nurs…
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psnet.ahrq.gov/node/73413/psn-pdf
June 23, 2021 - Interventions to reduce pediatric prescribing errors in
professional healthcare settings: a systematic review of
the last decade.
June 23, 2021
Koeck JA, Young NJ, Kontny U, et al. Interventions to Reduce Pediatric Prescribing Errors in Professional
Healthcare Settings: A Systematic Review of the Last Decade. Pedi…
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psnet.ahrq.gov/node/73506/psn-pdf
July 21, 2021 - Patient-safety incidents during COVID-19 health crisis in
France: An exploratory sequential multi-method study in
primary care.
July 21, 2021
Fournier JP, Amélineau JB, Hild S, et al. Eur J Gen Pract. 2021;27(1):142-151.
https://psnet.ahrq.gov/issue/patient-safety-incidents-during-covid-19-health-crisis-france-exp…
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psnet.ahrq.gov/node/73705/psn-pdf
September 15, 2021 - Do patient engagement interventions work for all
patients? A systematic review and realist synthesis of
interventions to enhance patient safety.
September 15, 2021
Newman B, Joseph K, Chauhan A, et al. Do patient engagement interventions work for all patients? A
systematic review and realist synthesis of intervent…