-
psnet.ahrq.gov/node/50399/psn-pdf
January 01, 2020 - Building the bridge to quality: an urgent call to integrate
quality improvement and patient safety education with
clinical care
October 2, 2019
Wong BM, Baum KD, Headrick LA, et al. Building the bridge to quality: an urgent call to integrate quality
improvement and patient safety education with clinical care. Acad…
-
psnet.ahrq.gov/node/40547/psn-pdf
June 29, 2011 - What context features might be important determinants of
the effectiveness of patient safety practice interventions?
June 29, 2011
Taylor SL, Dy SM, Foy R, et al. What context features might be important determinants of the effectiveness
of patient safety practice interventions? BMJ Qual Saf. 2011;20(7):611-7. doi:…
-
psnet.ahrq.gov/node/44547/psn-pdf
November 25, 2015 - Monitoring patient safety in primary care: an exploratory
study using in-depth semistructured interviews.
November 25, 2015
Samra R, Bottle A, Aylin PP. Monitoring patient safety in primary care: an exploratory study using in-depth
semistructured interviews. BMJ Open. 2015;5(9):e008128. doi:10.1136/bmjopen-2015-008…
-
psnet.ahrq.gov/node/74722/psn-pdf
February 02, 2022 - Preventing and mitigating radiology system failures: a
guide to disaster planning.
February 2, 2022
Gibney BT, Roberts JM, D'Ortenzio RM, et al. Preventing and mitigating radiology system failures: a guide
to disaster planning. RadioGraphics. 2021;41(7):2111-2126. doi:10.1148/rg.2021210083.
https://psnet.ahrq.gov/…
-
psnet.ahrq.gov/node/48159/psn-pdf
July 31, 2019 - Fatigue in radiology: a fertile area for future research.
July 31, 2019
Taylor-Phillips S, Stinton C. Fatigue in radiology: a fertile area for future research. Br J Radiol.
2019;92(1099):20190043. doi:10.1259/bjr.20190043.
https://psnet.ahrq.gov/issue/fatigue-radiology-fertile-area-future-research
Physician fatigu…
-
psnet.ahrq.gov/node/836714/psn-pdf
March 09, 2022 - Intraoperative deaths: who, why, and can we prevent
them?
March 9, 2022
Dorken Gallastegi A, Mikdad S, Kapoen C, et al. Intraoperative deaths: who, why, and can we prevent
them? J Surg Res. 2022;274:185-195. doi:10.1016/j.jss.2022.01.007.
https://psnet.ahrq.gov/issue/intraoperative-deaths-who-why-and-can-we-preven…
-
psnet.ahrq.gov/node/43726/psn-pdf
September 01, 2016 - Differences of reasons for alert overrides on
contraindicated co-prescriptions by admitting
department.
September 1, 2016
Ahn EK, Cho S-Y, Shin D, et al. Differences of Reasons for Alert Overrides on Contraindicated Co-
prescriptions by Admitting Department. Healthc Inform Res. 2014;20(4):280-7.
doi:10.4258/hir.2…
-
psnet.ahrq.gov/node/41392/psn-pdf
July 02, 2014 - Exploring error in team-based acute care scenarios: an
observational study from the United Kingdom.
July 2, 2014
Tallentire VR, Smith SE, Skinner J, et al. Exploring error in team-based acute care scenarios: an
observational study from the United kingdom. Acad Med. 2012;87(6):792-8.
doi:10.1097/ACM.0b013e318253c9e…
-
psnet.ahrq.gov/node/47959/psn-pdf
May 15, 2019 - A quality improvement initiative to reduce safety events
among adolescents hospitalized after a suicide attempt.
May 15, 2019
Noelck M, Velazquez-Campbell M, Austin JP. A Quality Improvement Initiative to Reduce Safety Events
Among Adolescents Hospitalized After a Suicide Attempt. Hosp Pediatr. 2019;9(5):365-372.
…
-
psnet.ahrq.gov/node/844796/psn-pdf
September 18, 2019 - Workplace violence against anesthesiologists: we are not
immune to this patient safety threat.
September 18, 2019
Udoji MA, Ifeanyi-Pillette IC, Miller TR, Lin DM. Int Anesthesiol Clin. 2019;57:123-137.
https://psnet.ahrq.gov/issue/workplace-violence-against-anesthesiologists-we-are-not-immune-patient-
safety-thre…
-
psnet.ahrq.gov/node/38589/psn-pdf
May 04, 2010 - Framing family conversation after early diagnosis of
iatrogenic injury and incidental findings.
May 4, 2010
Barrios L, Tsuda S, Derevianko A, et al. Framing family conversation after early diagnosis of iatrogenic
injury and incidental findings. Surg Endosc. 2009;23(11):2535-42. doi:10.1007/s00464-009-0450-2.
https…
-
psnet.ahrq.gov/node/47843/psn-pdf
March 06, 2019 - Structural iatrogenesis—a 43-year-old man with "opioid
misuse."
March 6, 2019
Stonington S, Coffa D. Structural Iatrogenesis - A 43-Year-Old Man with "Opioid Misuse". N Engl J Med.
2019;380(8):701-704. doi:10.1056/NEJMp1811473.
https://psnet.ahrq.gov/issue/structural-iatrogenesis-43-year-old-man-opioid-misuse
The…
-
psnet.ahrq.gov/node/44627/psn-pdf
May 30, 2016 - Exploring attitudes and opinions of pharmacists toward
delivering prescribing error feedback: a qualitative case
study using focus group interviews.
May 30, 2016
Lloyd M, Watmough SD, O'Brien S, et al. Exploring attitudes and opinions of pharmacists toward delivering
prescribing error feedback: A qualitative case …
-
psnet.ahrq.gov/node/854387/psn-pdf
October 11, 2023 - Healthcare resilience: a meta-narrative systematic review
and synthesis of reviews.
October 11, 2023
Tan MZY, Prager G, McClelland A, et al. Healthcare resilience: a meta-narrative systematic review and
synthesis of reviews. BMJ Open. 2023;13(9):e072136. doi:10.1136/bmjopen-2023-072136.
https://psnet.ahrq.gov/issu…
-
psnet.ahrq.gov/node/46258/psn-pdf
January 01, 2021 - Development of a trigger tool to identify adverse drug
events in elderly patients with multimorbidity.
August 30, 2017
Guzmán MDT, Banqueri MG, Otero MJ, et al. Development of a Trigger Tool to Identify Adverse Drug
Events in Elderly Patients With Multimorbidity. J Patient Saf. 2021;17(6):e475-e482.
doi:10.1097/PT…
-
psnet.ahrq.gov/node/36505/psn-pdf
February 16, 2011 - Complying with ACGME resident duty hours restrictions:
restructuring the 80-hour workweek to enhance education
and patient safety at Texas A&M/Scott & White Memorial
Hospital.
February 16, 2011
Ogden PE, Sibbitt S, Howell M, et al. Complying with ACGME resident duty hours restrictions: restructuring
the 80-hour w…
-
psnet.ahrq.gov/node/47179/psn-pdf
September 26, 2018 - Classification of patient-safety incidents in primary care.
September 26, 2018
Cooper J, Williams H, Hibbert P, et al. Classification of patient-safety incidents in primary care. Bull World
Health Organ. 2018;96(7):498-505. doi:10.2471/BLT.17.199802.
https://psnet.ahrq.gov/issue/classification-patient-safety-incide…
-
psnet.ahrq.gov/node/34652/psn-pdf
March 04, 2011 - Epidemiology of medical error.
March 4, 2011
Weingart SN, Wilson R, Gibberd RW, et al. Epidemiology of medical error. BMJ. 2000;320(7237):774-7.
https://psnet.ahrq.gov/issue/epidemiology-medical-error
This article summarizes the epidemiology of medical errors. The authors provide findings from benchmark
studies to…
-
psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-summary
February 26, 2025 - [Available at]
Summary
This innovation describes the Veteran Health Administration (VHA) National
-
psnet.ahrq.gov/node/49393/psn-pdf
April 01, 2003 - The Commentary
This case describes an uncommon but much feared complication in laparoscopic surgery—creation