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psnet.ahrq.gov/node/74158/psn-pdf
December 08, 2021 - An analysis of the structure and content of dashboards
used to monitor patient safety in the inpatient setting.
December 8, 2021
Kuznetsova M, Frits ML, Dulgarian S, et al. An analysis of the structure and content of dashboards used to
monitor patient safety in the inpatient setting. JAMIA Open. 2021;4(4):ooab096.
…
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psnet.ahrq.gov/node/843320/psn-pdf
February 01, 2023 - Society for Maternal-Fetal Medicine Special Statement:
telemedicine in obstetrics-quality and safety
considerations.
February 1, 2023
Healy A, Davidson C, Allbert J, et al. Society for Maternal-Fetal Medicine Special Statement: telemedicine
in obstetrics-quality and safety considerations. Am J Obstet Gynecol. 2023…
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psnet.ahrq.gov/node/73293/psn-pdf
May 19, 2021 - Exploring the barriers and facilitators of psychological
safety in primary care teams: a qualitative study.
May 19, 2021
Remtulla R, Hagana A, Houbby N, et al. Exploring the barriers and facilitators of psychological safety in
primary care teams: a qualitative study. BMC Health Serv Res. 2021;21(1):269. doi:10.1186…
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psnet.ahrq.gov/node/60184/psn-pdf
April 01, 2020 - Patient perspectives on the use of artificial intelligence
for skin cancer screening: a qualitative study.
April 1, 2020
Nelson CA, Pérez-Chada LM, Creadore A, et al. Patient perspectives on the use of artificial intelligence for
skin cancer screening: a qualitative study. JAMA Dermatol. 2020;156(5):501-512.
doi:1…
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psnet.ahrq.gov/node/39032/psn-pdf
September 19, 2016 - The natural history of recovery for the healthcare provider
"second victim" after adverse patient events.
September 19, 2016
Scott SD, Hirschinger LE, Cox KR, et al. The natural history of recovery for the healthcare provider "second
victim" after adverse patient events. Qual Saf Health Care. 2009;18(5):325-330.
d…
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psnet.ahrq.gov/node/35242/psn-pdf
February 24, 2011 - What can hospitalized patients tell us about adverse
events? Learning from patient-reported incidents.
February 24, 2011
Weingart SN, Pagovich O, Sands DZ, et al. What can hospitalized patients tell us about adverse events?
Learning from patient-reported incidents. J Gen Intern Med. 2005;20(9):830-6.
https://psnet…
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psnet.ahrq.gov/node/60530/psn-pdf
January 01, 2022 - A systematic review of patient-report safety climate
measures in health care.
May 27, 2020
Madden C, Lydon S, O’Dowd E, et al. A systematic review of patient-report safety climate measures in
health care. J Patient Saf. 2022;18(1):e51-e60. doi:10.1097/pts.0000000000000705.
https://psnet.ahrq.gov/issue/systematic-r…
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psnet.ahrq.gov/node/46044/psn-pdf
December 21, 2017 - Addressing the opioid epidemic in the United States:
lessons from the Department of Veterans Affairs.
December 21, 2017
Gellad WF, Good CB, Shulkin DJ. Addressing the Opioid Epidemic in the United States: Lessons From the
Department of Veterans Affairs. AMA Intern Med. 2017;177(5):611-612.
doi:10.1001/jamainternme…
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psnet.ahrq.gov/node/838248/psn-pdf
October 05, 2022 - The relationship between resident physician burnout and
its’ effects on patient care, professionalism, and
academic achievement: a review of the literature.
October 5, 2022
McTaggart LS, Walker JP. The relationship between resident physician burnout and its’ effects on patient
care, professionalism, and academic a…
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psnet.ahrq.gov/node/44949/psn-pdf
February 01, 2019 - Detecting and treating suicide ideation in all settings.
December 23, 2016
Detecting and treating suicide ideation in all settings. Sentinel event alert. 2016;(56):1-7.
https://psnet.ahrq.gov/issue/detecting-and-treating-suicide-ideation-all-settings
The Joint Commission publishes sentinel event alerts to emphasize…
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psnet.ahrq.gov/node/47902/psn-pdf
April 24, 2019 - Recommendations from a national panel on quality
improvement in obstetrics.
April 24, 2019
Lefebvre G, Calder LA, De Gorter R, et al. Recommendations From a National Panel on Quality
Improvement in Obstetrics. J Obstet Gynaecol Can. 2019;41(5):653-659. doi:10.1016/j.jogc.2019.02.011.
https://psnet.ahrq.gov/issue/r…
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psnet.ahrq.gov/node/60045/psn-pdf
March 18, 2020 - Making Healthcare Safer III.
March 18, 2020
Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March
2020. AHRQ Publication No. 20-0029-EF.
https://psnet.ahrq.gov/issue/making-healthcare-safer-iii
This newly issued follow up to the seminal AHRQ Making Health Care Safer rep…
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psnet.ahrq.gov/node/862617/psn-pdf
February 14, 2024 - Risks to Medication Delivery Using Ambulatory Infusion
Pumps – Design and Usability in Inpatient Settings.
February 14, 2024
Dorset, UK: Health Services Safety Investigations Body; November 2023.
https://psnet.ahrq.gov/issue/risks-medication-delivery-using-ambulatory-infusion-pumps-design-and-
usability-inpatient
…
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psnet.ahrq.gov/node/74189/psn-pdf
January 01, 2022 - US emergency department visits for acute harms from
over-the-counter cough and cold medications, 2017-2019.
December 15, 2021
Mital R, Lovegrove MC, Moro RN, et al. US emergency department visits for acute harms from over-the-
counter cough and cold medications, 2017-2019. Pharmacoepidemiol Drug Saf. 2022;31(2):225…
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psnet.ahrq.gov/node/47754/psn-pdf
April 17, 2019 - FDA identifies harm reported from sudden
discontinuation of opioid pain medicines and requires
label changes to guide prescribers on gradual,
individualized tapering.
April 17, 2019
Silver Spring, MD: US Food and Drug Administration; April 9, 2019.
https://psnet.ahrq.gov/issue/fda-identifies-harm-reported-sudden-…
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psnet.ahrq.gov/node/34642/psn-pdf
June 24, 2015 - Human factor in cardiac surgery: errors and near misses
in a high technology medical domain.
June 24, 2015
Carthey J, de Leval MR, Reason JT. The human factor in cardiac surgery: errors and near misses in a high
technology medical domain. Ann Thorac Surg. 2001;72(1):300-5.
https://psnet.ahrq.gov/issue/human-factor…
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psnet.ahrq.gov/node/46705/psn-pdf
March 21, 2018 - A national study links nurses' physical and mental health
to medical errors and perceived worksite wellness.
March 21, 2018
Melnyk BM, Orsolini L, Tan A, et al. A National Study Links Nurses' Physical and Mental Health to Medical
Errors and Perceived Worksite Wellness. J Occup Environ Med. 2018;60(2):126-131.
doi:…
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psnet.ahrq.gov/node/44483/psn-pdf
September 09, 2015 - Learning Not Blaming.
September 9, 2015
Department of Health and Social Care. London, England: Crown Publishing; July 2015. ISBN:
9781474123716.
https://psnet.ahrq.gov/issue/learning-not-blaming
The National Health Service (NHS) has a history of sharing analyses of problems in its system. This
publication contain…
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psnet.ahrq.gov/node/72790/psn-pdf
March 03, 2021 - Parent engagement in perinatal mortality reviews: an
online survey of clinicians from six high-income
countries.
March 3, 2021
Boyle FM, Horey D, Siassakos D, et al. Parent engagement in perinatal mortality reviews: an online survey
of clinicians from six high?income countries. BJOG. 2020;128(4):696-703. doi:10.11…
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psnet.ahrq.gov/node/46862/psn-pdf
February 21, 2018 - Considering human factors and developing systems-
thinking behaviours to ensure patient safety.
February 21, 2018
Vosper H; Lim R; Knight C; et al; CIEHF Pharmaceutical Human Factors Special Interest Group. Clinical
Pharmacist. 2018;10(2).
https://psnet.ahrq.gov/issue/considering-human-factors-and-developing-syste…