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psnet.ahrq.gov/node/50913/psn-pdf
February 19, 2020 - "Disruptive behavior" in the operating room: A
prospective observational study of triggers and effects of
tense communication episodes in surgical teams.
February 19, 2020
Keller S, Tschan F, Semmer NK, et al. “Disruptive behavior” in the operating room: A prospective
observational study of triggers and effects of…
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psnet.ahrq.gov/node/60636/psn-pdf
July 01, 2020 - Measuring the impact of medication-related interventions
on 30-day readmission rates in a skilled nursing facility.
July 1, 2020
Amin PB, Bradford CD, Rizos AL, et al. Measuring the Impact of Medication-Related Interventions on 30-
Day Readmission Rates in a Skilled Nursing Facility. J Pharm Pract. 2020;33(3):306-3…
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psnet.ahrq.gov/node/74191/psn-pdf
December 15, 2021 - Race differences in reported "near miss" patient safety
events in health care system high reliability
organizations.
December 15, 2021
Thomas AD, Pandit C, Krevat S. Race differences in reported "near miss" patient safety events in health
care system high reliability organizations. J Patient Saf. 2021;17(8):e1605-…
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psnet.ahrq.gov/node/837044/psn-pdf
May 04, 2022 - How Discrimination in Health Care Affects Older
Americans, and What Health Systems and Providers Can
Do.
May 4, 2022
Doty MM, Horstman C, Shah A et al. Issue Brief. New York, NY: Commonwealth Fund: April 2022.
https://psnet.ahrq.gov/issue/how-discrimination-health-care-affects-older-americans-and-what-health-
sys…
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psnet.ahrq.gov/node/836760/psn-pdf
March 16, 2022 - Comprehensive Healthcare Inspection Summary Report:
Evaluation of Mental Health in Veterans Health
Administration Facilities, Fiscal Year 2020.
March 16, 2022
Washington, DC: VA Office of the Inspector General; February 17, 2022. Report No. 21-01506-76.
https://psnet.ahrq.gov/issue/comprehensive-healthcare-i…
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psnet.ahrq.gov/node/845353/psn-pdf
March 01, 2023 - Inadequate Outpatient Mental Health Triage and Care of a
Patient at the Chico Community-Based Outpatient Clinic
in California.
March 1, 2023
Washington, DC: VA Office of the Inspector General; February 2, 2023. Report no. 22-01363-52.
https://psnet.ahrq.gov/issue/inadequate-outpatient-mental-health-triage-and…
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psnet.ahrq.gov/node/850170/psn-pdf
June 07, 2023 - A scoping review of distributed cognition in acute care
clinical decision-making.
June 7, 2023
Wilson E, Daniel M, Rao A, et al. A scoping review of distributed cognition in acute care clinical decision-
making. Diagnosis (Berl). 2023;10(2):68-88. doi:10.1515/dx-2022-0095.
https://psnet.ahrq.gov/issue/scoping-revi…
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psnet.ahrq.gov/node/74086/psn-pdf
November 17, 2021 - Review of reported adverse events occurring among the
homeless veteran population in the Veterans Health
Administration.
November 17, 2021
Soncrant C, Mills PD, Pendley Louis RP, et al. Review of reported adverse events occurring among the
homeless veteran population in the Veterans Health Administration. J Patien…
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psnet.ahrq.gov/node/847054/psn-pdf
April 05, 2023 - Patient generated research priorities to improve
diagnostic safety: a systematic prioritization exercise.
April 5, 2023
Zwaan L, Smith KM, Giardina TD, et al. Patient generated research priorities to improve diagnostic safety:
a systematic prioritization exercise. Patient Educ Couns. 2023;110:107650.
doi:10.1016/j…
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psnet.ahrq.gov/node/50651/psn-pdf
November 13, 2019 - How effective is teamwork really? The relationship
between teamwork and performance in healthcare teams:
a systematic review and meta-analysis.
November 13, 2019
Schmutz JB, Meier LL, Manser T. How effective is teamwork really? The relationship between teamwork
and performance in healthcare teams: a systematic rev…
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psnet.ahrq.gov/node/47487/psn-pdf
November 07, 2018 - Comparative, cross-sectional study of the format, content
and timing of medication safety letters issued in Canada,
the USA and the UK.
November 7, 2018
Bjerre LM, Parlow S, de Launay D, et al. Comparative, cross-sectional study of the format, content and
timing of medication safety letters issued in Canada, the U…
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psnet.ahrq.gov/issue/communication-and-resolution-programs-emerging-best-practice-addressing-patient-harm
July 29, 2020 - Upcoming Meeting/Conference
Communication and Resolution Programs: An Emerging Best Practice for Addressing Patient Harm.
Citation Text:
National Association for Healthcare Quality. August 26, 2021, 1:00–2:00 PM (eastern).
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psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
November 08, 2013 - Diffusion of Responsibility Leads to Danger
Citation Text:
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/47081/psn-pdf
September 02, 2018 - Beyond Dr. Google: the evidence on consumer-facing
digital tools for diagnosis.
September 2, 2018
Millenson ML, Baldwin JL, Zipperer L, et al. Beyond Dr. Google: the evidence on consumer-facing digital
tools for diagnosis. Diagnosis (Berl). 2018;5(3):95-105. doi:10.1515/dx-2018-0009.
https://psnet.ahrq.gov/issue/b…
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psnet.ahrq.gov/node/44174/psn-pdf
January 06, 2016 - Team training for safer birth.
January 6, 2016
Cornthwaite K, Alvarez M, Siassakos D. Team training for safer birth. Best Pract Res Clin Obstet Gynaecol.
2015;29(8):1044-1057. doi:10.1016/j.bpobgyn.2015.03.020.
https://psnet.ahrq.gov/issue/team-training-safer-birth
Obstetric care is considered a high-risk environm…
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psnet.ahrq.gov/node/42556/psn-pdf
August 28, 2013 - Findings and Lessons From the Improving Quality
Through Clinician Use of Health IT Grant Initiative.
August 28, 2013
Rockville, MD: Agency for Healthcare Research and Quality. May 2013. AHRQ Publication No 13-0042-EF.
https://psnet.ahrq.gov/issue/findings-and-lessons-improving-quality-through-clinician-use-health-i…
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psnet.ahrq.gov/node/36122/psn-pdf
January 05, 2017 - Using an MET service to manage hemorrhage post-
percutaneous liver biopsy.
January 5, 2017
Jones D, Bellomo R, Leong T. Using an MET service to manage hemorrhage post-percutaneous liver
biopsy. Jt Comm J Qual Patient Saf. 2006;32(8):459-62, 417.
https://psnet.ahrq.gov/issue/using-met-service-manage-hemorrhage-post…
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psnet.ahrq.gov/node/34570/psn-pdf
March 07, 2005 - Measuring the Success of the Regional Medication Safety
Program for Hospitals.
March 7, 2005
Pelczarski K, Fricker M, Morris J. Philadelphia, PA: Health Care Improvement Foundation; 2005.
https://psnet.ahrq.gov/issue/measuring-success-regional-medication-safety-program-hospitals
The Regional Medication Safety Prog…
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psnet.ahrq.gov/node/33882/psn-pdf
June 01, 2019 - Building a Safety Program Using Principles of Resilience
Engineering
June 1, 2019
Hegde S, Fairbanks RJ, Bisantz A. Building a Safety Program Using Principles of Resilience Engineering.
PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
Persp…
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psnet.ahrq.gov/primer/pharmacists-role-medication-safety
March 14, 2018 - Pharmacist's Role in Medication Safety
Citation Text:
The Pharmacist's Role in Medication Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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