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psnet.ahrq.gov/node/47525/psn-pdf
October 31, 2018 - Peer training using cognitive rehearsal to promote a
culture of safety in health care.
October 31, 2018
Roberts T, Hanna K, Hurley S, et al. Peer Training Using Cognitive Rehearsal to Promote a Culture of
Safety in Health Care. Nurse Educ. 2018;43(5):262-266. doi:10.1097/NNE.0000000000000478.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/46260/psn-pdf
July 26, 2017 - ACOG Committee opinion #680: the use and development
of checklists in obstetrics and gynecology.
July 26, 2017
American College of Obstetricians and Gynecologists’ Committee on Patient Safety and Quality
Improvement. Obstet Gynecol. 2016;128:e237-e240.
https://psnet.ahrq.gov/issue/acog-committee-opinion-680-use-an…
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psnet.ahrq.gov/node/45044/psn-pdf
May 11, 2016 - Creating a nurse-led culture to minimize horizontal
violence in the acute care setting: a multi-interventional
approach.
May 11, 2016
Parker KM, Harrington A, Smith CM, et al. Creating a Nurse-Led Culture to Minimize Horizontal Violence in
the Acute Care Setting: A Multi-Interventional Approach. J Nurses Prof Dev.…
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psnet.ahrq.gov/node/36276/psn-pdf
October 21, 2010 - Effects of nursing rounds on patients' call light use,
satisfaction, and safety.
October 21, 2010
Meade CM, Bursell AL, Ketelsen L. Effects of nursing rounds: on patients' call light use, satisfaction, and
safety. Am J Nurs. 2006;106(9):58-71.
https://psnet.ahrq.gov/issue/effects-nursing-rounds-patients-call-light…
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psnet.ahrq.gov/node/44730/psn-pdf
December 08, 2015 - Why studying human behavior is a critical component of
patient safety.
December 8, 2015
Su L. Why Studying Human Behavior is a Critical Component of Patient Safety. Curr Probl Pediatr Adolesc
Health Care. 2015;45(12):367-9. doi:10.1016/j.cppeds.2015.10.004.
https://psnet.ahrq.gov/issue/why-studying-human-behavior-…
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psnet.ahrq.gov/node/44681/psn-pdf
April 13, 2016 - Triggers, bundles, protocols, and checklists—what every
maternal care provider needs to know.
April 13, 2016
Arora KS, Shields LE, Grobman WA, et al. Triggers, bundles, protocols, and checklists--what every
maternal care provider needs to know. Am J Obstet Gynecol. 2016;214(4):444-451.
doi:10.1016/j.ajog.2015.10.0…
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psnet.ahrq.gov/node/35361/psn-pdf
July 16, 2009 - Improving Patient Safety Through Informed Consent for
Patients with Limited Health Literacy.
July 16, 2009
Wu HW, Nishimi RY, Page-Lopez CM, et al. Washington DC: National Quality Forum; 2005.
https://psnet.ahrq.gov/issue/improving-patient-safety-through-informed-consent-patients-limited-health-
literacy
In the 2…
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psnet.ahrq.gov/node/855424/psn-pdf
November 15, 2023 - Medical students' experiences, perceptions, and
management of second victim: an interview study.
November 15, 2023
Krogh TB, Mielke-Christensen A, Madsen MD, et al. Medical students’ experiences, perceptions, and
management of second victim: an interview study. BMC Med Educ. 2023;23(1):786. doi:10.1186/s12909-
023…
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psnet.ahrq.gov/node/838145/psn-pdf
September 21, 2022 - Charlie Bourg was on the lookout for veterans harmed by
a new VA computer system. He didn’t expect to be one of
them.
September 21, 2022
Donovan-Smith O. Spokesman-Review. September 11, 2022.
https://psnet.ahrq.gov/issue/charlie-bourg-was-lookout-veterans-harmed-new-va-computer-system-he-
didnt-expect-be-one…
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psnet.ahrq.gov/node/43828/psn-pdf
January 14, 2015 - Tragic error with neuromuscular blocker should prompt
risk assessment by all hospitals.
January 14, 2015
ISMP Medication Safety Alert! Acute Care Edition. December 18, 2014;19:1,4.
https://psnet.ahrq.gov/issue/tragic-error-neuromuscular-blocker-should-prompt-risk-assessment-all-
hospitals
This newsletter article …
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psnet.ahrq.gov/node/43982/psn-pdf
April 01, 2015 - Human factors and ergonomics and quality improvement
science: integrating approaches for safety in healthcare.
April 1, 2015
Hignett S, Jones EL, Miller D, et al. Human factors and ergonomics and quality improvement science:
integrating approaches for safety in healthcare. BMJ Qual Saf. 2015;24(4):250-254. doi:10.1…
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psnet.ahrq.gov/node/36947/psn-pdf
September 09, 2011 - The safety of warfarin therapy in the nursing home
setting.
September 9, 2011
Gurwitz JH, Field T, Radford MJ, et al. The safety of warfarin therapy in the nursing home setting. Am J
Med. 2007;120(6):539-44.
https://psnet.ahrq.gov/issue/safety-warfarin-therapy-nursing-home-setting
The anticoagulant warfarin is co…
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psnet.ahrq.gov/node/61094/psn-pdf
November 04, 2020 - The doctor was rude, the toilets are dirty. Utilizing 'soft
signals' in the regulation of patient safety.
November 4, 2020
Kok J, Wallenburg I, Leistikow I, et al. The doctor was rude, the toilets are dirty. Utilizing ‘soft signals’ in the
regulation of patient safety. Safety Sci. 2020;131:104914. doi:10.1016/j.ssc…
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psnet.ahrq.gov/node/47756/psn-pdf
February 06, 2019 - Meltdown: Why Our Systems Fail and What We Can Do
About It.
February 6, 2019
Clearfield C, Tilcsik A. New York, NY: Penguin Press; 2018. ISBN: 978-0735222632.
https://psnet.ahrq.gov/issue/meltdown-why-our-systems-fail-and-what-we-can-do-about-it
Complex systems are prone to failure. This book provides a multi-indu…
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psnet.ahrq.gov/node/43521/psn-pdf
November 05, 2014 - From Science to Implementation: AHRQ's Program to
Prevent HAIs—Results and Lessons.
November 5, 2014
Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Am J Infect Control. 2014;42(suppl 10):S189-S296.
https://psnet.ahrq.gov/issue/science-implementation-ahrqs-program-prevent-hais-results-and-lessons
This companion…
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psnet.ahrq.gov/node/867759/psn-pdf
March 12, 2025 - Intrahospital patient transport: checklists, adverse
events, and other considerations for the anesthesia
professional.
March 12, 2025
Andrew C, Fitzsimons M. Intrahospital patient transport: checklists, adverse events, and other
considerations for the anesthesia professional. APSF Newsletter. 2025;40(1):24-26.
ht…
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psnet.ahrq.gov/node/73166/psn-pdf
April 21, 2021 - Trust and medical AI: the challenges we face and the
expertise needed to overcome them.
April 21, 2021
Quinn TP, Senadeera M, Jacobs S, et al. Trust and medical AI: the challenges we face and the expertise
needed to overcome them. J Amer Med Inform Assoc. 2021;28(4):890-894. doi:10.1093/jamia/ocaa268.
https://psne…
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psnet.ahrq.gov/node/73708/psn-pdf
September 15, 2021 - Patient safety and ethical implications of healthcare sick
leave policies in the pandemic era.
September 15, 2021
Preston-Suni K, Celedon MA, Cordasco KM. Patient safety and ethical implications of healthcare sick leave
policies in the pandemic era. Jt Comm J Qual Patient Saf. 2021;47(10):673-676.
doi:10.1016/j.jc…
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psnet.ahrq.gov/node/45102/psn-pdf
May 18, 2016 - Inappropriate preinjury warfarin use in trauma patients: a
call for a safety initiative.
May 18, 2016
Hon HH, Elmously A, Stehly CD, et al. Inappropriate preinjury warfarin use in trauma patients: A call for a
safety initiative. J Postgrad Med. 2016;62(2):73-9. doi:10.4103/0022-3859.175004.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/35648/psn-pdf
February 03, 2011 - The 100,000 Lives Campaign: setting a goal and a
deadline for improving health care quality.
February 3, 2011
Berwick DM, Calkins DR, McCannon CJ, et al. The 100 000 Lives Campaign. JAMA. 2006;295(3).
doi:10.1001/jama.295.3.324.
https://psnet.ahrq.gov/issue/100000-lives-campaign-setting-goal-and-deadline-improving…