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psnet.ahrq.gov/node/48095/psn-pdf
June 26, 2019 - Exposure to incivility hinders clinical performance in a
simulated operative crisis.
June 26, 2019
Katz D, Blasius K, Isaak R, et al. Exposure to incivility hinders clinical performance in a simulated operative
crisis. BMJ Qual Saf. 2019;28(9):750-757. doi:10.1136/bmjqs-2019-009598.
https://psnet.ahrq.gov/issue/ex…
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psnet.ahrq.gov/node/74853/psn-pdf
February 24, 2022 - The Top Six: standardized safety practices in U.S. Army
Medical Department treatment facilities worldwide.
February 24, 2022
Hartstein B, Munante M, Toor PA. The Top Six: Standardized safety practices in U.S. Army Medical
Department treatment facilities worldwide. NEJM Catal Innov Care Deliv. 2022;3(2):e1-e20.
doi…
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psnet.ahrq.gov/node/47226/psn-pdf
August 01, 2018 - Development of a standardized, citywide process for
managing smart-pump drug libraries.
August 1, 2018
Walroth TA, Smallwood S, Arthur KJ, et al. Development of a standardized, citywide process for managing
smart-pump drug libraries. Am J Health Syst Pharm. 2018;75(12):893-900. doi:10.2146/ajhp170262.
https://psne…
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psnet.ahrq.gov/node/37622/psn-pdf
May 26, 2011 - Effect of computer order entry on prevention of serious
medication errors in hospitalized children.
May 26, 2011
Walsh KE, Landrigan CP, Adams WG, et al. Effect of computer order entry on prevention of serious
medication errors in hospitalized children. Pediatrics. 2008;121(3):e421-e427. doi:10.1542/peds.2007-
022…
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psnet.ahrq.gov/node/45405/psn-pdf
November 18, 2016 - Relationship between operating room teamwork,
contextual factors, and safety checklist performance.
November 18, 2016
Singer SJ, Molina G, Li Z, et al. Relationship Between Operating Room Teamwork, Contextual Factors,
and Safety Checklist Performance. J Am Coll Surg. 2016;223(4):568-580.e2.
doi:10.1016/j.jamcollsu…
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psnet.ahrq.gov/node/46932/psn-pdf
April 22, 2018 - Hospital Survey on Patient Safety Culture: 2018 User
Database Report.
April 22, 2018
Famolaro T, Yount N, Hare, R, et al. Rockville, MD: Agency for Healthcare Research and Quality; March
2018. AHRQ Publication No. 18-0025-EF.
https://psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2018-user-database-re…
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psnet.ahrq.gov/node/47150/psn-pdf
November 21, 2018 - Investigating the association of alerts from a national
mortality surveillance system with subsequent hospital
mortality in England: an interrupted time series analysis.
November 21, 2018
Cecil E, Bottle A, Esmail A, et al. Investigating the association of alerts from a national mortality
surveillance system with …
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psnet.ahrq.gov/node/39266/psn-pdf
March 05, 2010 - The impact of stress on surgical performance: a
systematic review of the literature.
March 5, 2010
Arora S, Sevdalis N, Nestel D, et al. The impact of stress on surgical performance: a systematic review of
the literature. Surgery. 2010;147(3):318-30, 330.e1-6. doi:10.1016/j.surg.2009.10.007.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/43074/psn-pdf
December 18, 2014 - Graded autonomy in medical education—managing
things that go bump in the night.
December 18, 2014
Halpern S, Detsky AS. Graded autonomy in medical education--managing things that go bump in the night.
N Engl J Med. 2014;370(12):1086-1089. doi:10.1056/NEJMp1315408.
https://psnet.ahrq.gov/issue/graded-autonomy-medic…
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psnet.ahrq.gov/node/38435/psn-pdf
February 25, 2009 - Prescribing discrepancies likely to cause adverse drug
events after patient transfer.
February 25, 2009
Boockvar KS, Liu S, Goldstein N, et al. Prescribing discrepancies likely to cause adverse drug events after
patient transfer. Qual Saf Health Care. 2009;18(1):32-6. doi:10.1136/qshc.2007.025957.
https://psnet.ah…
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psnet.ahrq.gov/node/40092/psn-pdf
December 22, 2010 - The value of adding a verbal report to written handoffs on
early readmission following prolonged respiratory failure.
December 22, 2010
Hess DR, Tokarczyk A, O'Malley M, et al. The value of adding a verbal report to written handoffs on early
readmission following prolonged respiratory failure. Chest. 2010;138(6):14…
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psnet.ahrq.gov/node/47136/psn-pdf
July 02, 2019 - Adherence to recommended electronic health record
safety practices across eight health care organizations.
July 2, 2019
Sittig DF, Salimi M, Aiyagari R, et al. Adherence to recommended electronic health record safety practices
across eight health care organizations. J Am Med Inform Assoc. 2018;25(7):913-918.
doi:1…
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psnet.ahrq.gov/node/35854/psn-pdf
February 09, 2011 - Safe but sound: patient safety meets evidence-based
medicine.
February 9, 2011
Shojania KG, Duncan BW, McDonald KM, et al. Safe but Sound. JAMA. 2003;288(4):508-513.
doi:10.1001/jama.288.4.508.
https://psnet.ahrq.gov/issue/safe-sound-patient-safety-meets-evidence-based-medicine
This commentary summarizes the work…
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psnet.ahrq.gov/node/45356/psn-pdf
May 09, 2017 - Screening for medication errors using an outlier detection
system.
May 9, 2017
Schiff G, Volk LA, Volodarskaya M, et al. Screening for medication errors using an outlier detection system.
J Am Med Inform Assoc. 2017;24(2):281-287. doi:10.1093/jamia/ocw171.
https://psnet.ahrq.gov/issue/screening-medication-errors-u…
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psnet.ahrq.gov/node/46616/psn-pdf
July 02, 2019 - Medication-related clinical decision support alert
overrides in inpatients.
July 2, 2019
Nanji KC, Seger DL, Slight SP, et al. Medication-related clinical decision support alert overrides in
inpatients. J Am Med Inform Assoc. 2018;25(5):476-481. doi:10.1093/jamia/ocx115.
https://psnet.ahrq.gov/issue/medication-rel…
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psnet.ahrq.gov/node/40785/psn-pdf
May 04, 2012 - A framework for evaluating the appropriateness of clinical
decision support alerts and responses.
May 4, 2012
McCoy AB, Waitman LR, Lewis JB, et al. A framework for evaluating the appropriateness of clinical
decision support alerts and responses. J Am Med Inform Assoc. 2012;19(3):346-52. doi:10.1136/amiajnl-
2011-…
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psnet.ahrq.gov/node/47603/psn-pdf
March 20, 2019 - Electronic patient identification for sample labeling
reduces wrong blood in tube errors.
March 20, 2019
Kaufman RM, Dinh A, Cohn CS, et al. Electronic patient identification for sample labeling reduces wrong
blood in tube errors. Transfusion (Paris). 2019;59(3):972-980. doi:10.1111/trf.15102.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/45344/psn-pdf
January 23, 2017 - Comparison of accuracy of physical examination findings
in initial progress notes between paper charts and a
newly implemented electronic health record.
January 23, 2017
Yadav S, Kazanji N, C. NK, et al. Comparison of accuracy of physical examination findings in initial
progress notes between paper charts and a ne…
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psnet.ahrq.gov/node/37908/psn-pdf
June 10, 2010 - Incidence and characteristics of potential and actual
retained foreign object events in surgical patients.
June 10, 2010
Cima RR, Kollengode A, Garnatz J, et al. Incidence and characteristics of potential and actual retained
foreign object events in surgical patients. J Am Coll Surg. 2008;207(1):80-7.
doi:10.1016/…
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psnet.ahrq.gov/node/41555/psn-pdf
January 03, 2017 - Measuring administrators' and direct care workers'
perceptions of the safety culture in assisted living
facilities.
January 3, 2017
Castle NG, Wagner LM, Sonon K, et al. Measuring administrators' and direct care workers' perceptions of
the safety culture in assisted living facilities. Jt Comm J Qual Patient Saf. 2…