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psnet.ahrq.gov/node/73156/psn-pdf
April 21, 2021 - Increasing naloxone prescribing in the emergency
department through education and electronic medical
record work-aids.
April 21, 2021
Funke M, Kaplan MC, Glover H, et al. Increasing naloxone prescribing in the emergency department
through education and electronic medical record work-aids. Jt Comm J Qual Patient Sa…
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psnet.ahrq.gov/node/38743/psn-pdf
January 03, 2017 - Refocusing the lens: patient safety in ambulatory chronic
disease care.
January 3, 2017
Sarkar U, Wachter R, Schroeder SA, et al. Refocusing the lens: patient safety in ambulatory chronic
disease care. Jt Comm J Qual Patient Saf. 2009;35(7):377-83, 341.
https://psnet.ahrq.gov/issue/refocusing-lens-patient-safety-a…
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psnet.ahrq.gov/node/50458/psn-pdf
October 09, 2019 - Success of a resident-led safety council: a model for
satisfying CLER Pathways to Excellence patient safety
goals.
October 9, 2019
Cohen SP, Pelletier JH, Ladd JM, et al. Success of a resident-led safety council: a model for satisfying
CLER Pathways to Excellence patient safety goals. J Gen Intern Med. 2019;11(2):…
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www.ahrq.gov/hai/tools/abate/training/videos.html
March 01, 2022 - Staff Training Videos
As part of this toolkit, videos provide background information about the A ctive Bat hing to E liminate (ABATE) Infection Trial, commonly encountered patient scenarios, and instructions on the proper techniques for cleaning central and midline catheters and lumbar drains with chlorhexid…
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psnet.ahrq.gov/node/47092/psn-pdf
October 13, 2018 - Organizational response to known medical errors: does
peer review protection impede improvement?
October 13, 2018
Wenner WJ, Choi SW. Organizational Response to Known Medical Errors: Does Peer Review Protection
Impede Improvement? Am J Med Qual. 2018;33(5):552-553. doi:10.1177/1062860618769429.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/37257/psn-pdf
April 19, 2011 - Validation of a diagnostic reminder system in emergency
medicine: a multi-centre study.
April 19, 2011
Ramnarayan P, Cronje N, Brown R, et al. Validation of a diagnostic reminder system in emergency
medicine: a multi-centre study. Emerg Med J. 2007;24(9):619-24.
https://psnet.ahrq.gov/issue/validation-diagnostic-r…
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psnet.ahrq.gov/node/37290/psn-pdf
February 15, 2011 - Medical errors involving trainees: a study of closed
malpractice claims from 5 insurers.
February 15, 2011
Singh H, Thomas EJ, Petersen L, et al. Medical errors involving trainees: a study of closed malpractice
claims from 5 insurers. Arch Intern Med. 2007;167(19):2030-6.
https://psnet.ahrq.gov/issue/medical-error…
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psnet.ahrq.gov/node/36836/psn-pdf
January 29, 2015 - Learning from Bristol: The Report of the Public Inquiry
into Children's Heart Surgery at the Bristol Royal
Infirmary 1984--1995.
January 29, 2015
Bristol Royal Infirmary Inquiry; The Stationery Office. London, England: Crown Copyright; 2002.
https://psnet.ahrq.gov/issue/learning-bristol-report-public-inquiry-child…
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psnet.ahrq.gov/node/36979/psn-pdf
February 28, 2011 - Changes in outcomes for internal medicine inpatients
after work-hour regulations.
February 28, 2011
Horwitz LI, Kosiborod M, Lin Z, et al. Changes in outcomes for internal medicine inpatients after work-hour
regulations. Ann Intern Med. 2007;147(2):97-103.
https://psnet.ahrq.gov/issue/changes-outcomes-internal-med…
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psnet.ahrq.gov/node/39396/psn-pdf
November 02, 2014 - Unmet Needs: Teaching Physicians to Provide Safe
Patient Care.
November 2, 2014
Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; March 2010.
https://psnet.ahrq.gov/issue/unmet-needs-teaching-physicians-provide-safe-patient-care
Medical schools face an urgent need to transform their cur…
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psnet.ahrq.gov/node/40473/psn-pdf
July 02, 2011 - A systematic review of failures in handoff communication
during intrahospital transfers.
July 2, 2011
Ong M-S, Coiera E. A systematic review of failures in handoff communication during intrahospital transfers.
Jt Comm J Qual Patient Saf. 2011;37(6):274-284.
https://psnet.ahrq.gov/issue/systematic-review-failures-h…
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psnet.ahrq.gov/node/43346/psn-pdf
August 02, 2015 - Diffusion of surgical innovations, patient safety, and
minimally invasive radical prostatectomy.
August 2, 2015
Parsons K, Messer K, Palazzi K, et al. Diffusion of surgical innovations, patient safety, and minimally
invasive radical prostatectomy. JAMA Surg. 2014;149(8):845-51. doi:10.1001/jamasurg.2014.31.
https:…
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psnet.ahrq.gov/node/39896/psn-pdf
July 03, 2014 - Effect of availability bias and reflective reasoning on
diagnostic accuracy among internal medicine residents.
July 3, 2014
Mamede S, Van Gog T, Van den Berge K, et al. Effect of availability bias and reflective reasoning on
diagnostic accuracy among internal medicine residents. JAMA. 2010;304(11):1198-1203.
doi:1…
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www.ahrq.gov/antibiotic-use/long-term-care/safety/index.html
January 01, 2024 - Create a Culture of Safety Around Antibiotic Prescribing
For information on how the materials below can be integrated into institutional efforts to improve antibiotic use, read the Implementation Guide for Long-Term Care Antibiotic Stewardship Programs (PDF, 402 KB).
Presentations
Improving antibi…
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psnet.ahrq.gov/node/38621/psn-pdf
February 18, 2011 - Process of care failures in breast cancer diagnosis.
February 18, 2011
Weingart SN, Saadeh MG, Simchowitz B, et al. Process of care failures in breast cancer diagnosis. J Gen
Intern Med. 2009;24(6):702-709. doi:10.1007/s11606-009-0982-0.
https://psnet.ahrq.gov/issue/process-care-failures-breast-cancer-diagnosis
Di…
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psnet.ahrq.gov/node/43401/psn-pdf
August 02, 2015 - Morning handover of on-call issues: opportunities for
improvement.
August 2, 2015
Devlin MK, Kozij NK, Kiss A, et al. Morning handover of on-call issues: opportunities for improvement.
JAMA Intern Med. 2014;174(9):1479-85. doi:10.1001/jamainternmed.2014.3033.
https://psnet.ahrq.gov/issue/morning-handover-call-issu…
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psnet.ahrq.gov/node/39063/psn-pdf
December 17, 2009 - Safety and risk management interventions in hospitals: a
systematic review of the literature.
December 17, 2009
Dückers M, Faber M, Cruijsberg J, et al. Safety and risk management interventions in hospitals: a
systematic review of the literature. Med Care Res Rev. 2009;66(6 Suppl):90S-119S.
doi:10.1177/10775587093…
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psnet.ahrq.gov/node/44683/psn-pdf
June 21, 2016 - Physician spending and subsequent risk of malpractice
claims: observational study.
June 21, 2016
Jena AB, Schoemaker L, Bhattacharya J, et al. Physician spending and subsequent risk of malpractice
claims: observational study. BMJ. 2015;351:h5516. doi:10.1136/bmj.h5516.
https://psnet.ahrq.gov/issue/physician-spendi…
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psnet.ahrq.gov/node/43176/psn-pdf
July 03, 2014 - Patient safety in the era of the 80-hour workweek.
July 3, 2014
Shelton J, Kummerow K, Phillips S, et al. Patient safety in the era of the 80-hour workweek. J Surg Educ.
2014;71(4):551-9. doi:10.1016/j.jsurg.2013.12.011.
https://psnet.ahrq.gov/issue/patient-safety-era-80-hour-workweek
Regulations intended to reduc…
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psnet.ahrq.gov/node/43174/psn-pdf
December 12, 2014 - Adverse drug event detection in pediatric oncology and
hematology patients: using medication triggers to identify
patient harm in a specialized pediatric patient population.
December 12, 2014
Call RJ, Burlison JD, Robertson JJ, et al. Adverse drug event detection in pediatric oncology and
hematology patients: usin…