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psnet.ahrq.gov/node/45728/psn-pdf
January 23, 2017 - Executive leadership and physician well-being: nine
organizational strategies to promote engagement and
reduce burnout.
January 23, 2017
Shanafelt TD, Noseworthy JH. Executive Leadership and Physician Well-being: Nine Organizational
Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 2017;92(1):12…
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psnet.ahrq.gov/node/45298/psn-pdf
April 22, 2017 - The problem with root cause analysis.
April 22, 2017
Peerally MF, Carr S, Waring J, et al. The problem with root cause analysis. BMJ Qual Saf. 2017;26(5):417-
422. doi:10.1136/bmjqs-2016-005511.
https://psnet.ahrq.gov/issue/problem-root-cause-analysis
Root cause analysis (RCA) is a strategy to investigate incident…
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psnet.ahrq.gov/node/42170/psn-pdf
May 10, 2013 - Understanding factors that impact on health care
professionals' risk perceptions and responses toward
Clostridium difficile and methicillin-resistant
Staphylococcus aureus: a structured literature review.
May 10, 2013
Burnett E, Kearney N, Johnston B, et al. Understanding factors that impact on health care profess…
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psnet.ahrq.gov/node/45736/psn-pdf
February 01, 2017 - Disruptive behaviour in the perioperative setting: a
contemporary review.
February 1, 2017
Villafranca A, Hamlin C, Enns S, et al. Disruptive behaviour in the perioperative setting: a contemporary
review. Canadian J Anaesth. 2017;64(2):128-140. doi:10.1007/s12630-016-0784-x.
https://psnet.ahrq.gov/issue/disruptive…
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psnet.ahrq.gov/node/43310/psn-pdf
July 09, 2014 - Antimicrobial stewardship: another focus for patient
safety?
July 9, 2014
Tamma PD, Holmes A, Ashley ED. Antimicrobial stewardship: another focus for patient safety? Curr Opin
Infect Dis. 2014;27(4):348-55. doi:10.1097/QCO.0000000000000077.
https://psnet.ahrq.gov/issue/antimicrobial-stewardship-another-focus-patie…
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psnet.ahrq.gov/node/74081/psn-pdf
November 17, 2021 - The influence of the availability heuristic on physicians in
the emergency department.
November 17, 2021
Ly DP. The influence of the availability heuristic on physicians in the emergency department. Ann Emerg
Med. 2021;78(5):650-657. doi:10.1016/j.annemergmed.2021.06.012.
https://psnet.ahrq.gov/issue/influence-ava…
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psnet.ahrq.gov/node/43645/psn-pdf
November 12, 2014 - Health IT and Clinical Decision Support Systems.
November 12, 2014
Ohno-Machado L, ed. J Am Med Inform Assoc. 2014;21:e180-e375.
https://psnet.ahrq.gov/issue/health-it-and-clinical-decision-support-systems
A universal agreement on how to calculate the return on investment for health information technology (IT)
and…
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psnet.ahrq.gov/node/840144/psn-pdf
November 16, 2022 - Dedicated teams to optimize quality and safety of
surgery: a systematic review.
November 16, 2022
Lentz CM, De Lind Van Wijngaarden RAF, Willeboordse F, et al. Dedicated teams to optimize quality and
safety of surgery: a systematic review. Int J Qual Health Care. 2022;34(4):mzac078.
doi:10.1093/intqhc/mzac078.
ht…
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psnet.ahrq.gov/node/46489/psn-pdf
January 01, 2021 - Intervening in interruptions: what exactly is the risk we
are trying to manage?
October 11, 2017
Gao J, Rae AJ, Dekker SWA. Intervening in Interruptions: What Exactly Is the Risk We Are Trying to
Manage? J Patient Saf. 2021;17(7):e684-e688. doi:10.1097/PTS.0000000000000429.
https://psnet.ahrq.gov/issue/intervening…
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psnet.ahrq.gov/node/47232/psn-pdf
November 14, 2018 - Managing alarm systems for quality and safety in the
hospital setting.
November 14, 2018
Bach TA, Berglund L-M, Turk E. Managing alarm systems for quality and safety in the hospital setting. BMJ
Open Qual. 2018;7(3):e000202. doi:10.1136/bmjoq-2017-000202.
https://psnet.ahrq.gov/issue/managing-alarm-systems-quality…
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psnet.ahrq.gov/node/73222/psn-pdf
May 05, 2021 - Fatal mistakes: why do ten-fold medication errors in
children keep happening?
May 5, 2021
Parry C. The Pharmaceutical Journal. April 22 2021.
https://psnet.ahrq.gov/issue/fatal-mistakes-why-do-ten-fold-medication-errors-children-keep-happening
Weight-based prescribing in children harbors challenges to accura…
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psnet.ahrq.gov/node/38779/psn-pdf
July 15, 2009 - Prospective risk analysis of health care processes: a
systematic evaluation of the use of HFMEA in Dutch
health care.
July 15, 2009
Habraken MMP, van der Schaaf TW, Leistikow IP, et al. Prospective risk analysis of health care processes:
a systematic evaluation of the use of HFMEA in Dutch health care. Ergonomics.…
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psnet.ahrq.gov/node/47503/psn-pdf
October 24, 2018 - I-PASS checklist: a powerful tool for patient handoffs.
October 24, 2018
Peeples L. Pharmacy Practice News. October 10, 2018.
https://psnet.ahrq.gov/issue/i-pass-checklist-powerful-tool-patient-handoffs
Structured handoffs can reduce communication problems that contribute to medical error. This magazine
article re…
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psnet.ahrq.gov/node/44911/psn-pdf
February 17, 2016 - Improving doctor–patient communication in a digital
world.
February 17, 2016
Lakshmanan I. The Diane Rehm Show. February 9, 2016.
https://psnet.ahrq.gov/issue/improving-doctor-patient-communication-digital-world
Digital technologies represent both promise and risks for communication in health care. This radio inte…
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psnet.ahrq.gov/node/34779/psn-pdf
December 21, 2014 - Measuring and managing quality of surgery. Statistical vs
incidental approaches.
December 21, 2014
McGuire HH, Horsley JS, Salter DR, et al. Measuring and managing quality of surgery. Statistical vs
incidental approaches. Arch Surg. 1992;127(6):733-7; discussion 738.
https://psnet.ahrq.gov/issue/measuring-and-mana…
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psnet.ahrq.gov/node/44187/psn-pdf
November 10, 2015 - A safe practice standard for barcode technology.
November 10, 2015
Leung AA, Denham CR, Gandhi TK, et al. A safe practice standard for barcode technology. J Patient Saf.
2015;11(2):89-99. doi:10.1097/PTS.0000000000000049.
https://psnet.ahrq.gov/issue/safe-practice-standard-barcode-technology
Barcode technology has…
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psnet.ahrq.gov/node/72470/psn-pdf
January 01, 2021 - Safe use of the EHR by medical scribes: a qualitative
study.
November 18, 2020
Ash JS, Corby S, Mohan V, et al. Safe use of the EHR by medical scribes: a qualitative study. J Amer Med
Inform Assoc. 2021;28(2):294-302. doi:10.1093/jamia/ocaa199.
https://psnet.ahrq.gov/issue/safe-use-ehr-medical-scribes-qualitative-…
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psnet.ahrq.gov/node/73858/psn-pdf
September 22, 2021 - Coping with errors in the operating room: intraoperative
strategies, postoperative strategies, and sex differences.
September 22, 2021
D'Angelo JD, Lund S, Busch RA, et al. Coping with errors in the operating room: intraoperative strategies,
postoperative strategies, and sex differences. Surgery. 2021;170(2):440-44…
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psnet.ahrq.gov/node/37631/psn-pdf
May 18, 2015 - The science of improvement.
May 18, 2015
Berwick DM. The science of improvement. JAMA. 2008;299(10):1182-4. doi:10.1001/jama.299.10.1182.
https://psnet.ahrq.gov/issue/science-improvement
This commentary by Dr. Donald Berwick, president of the Institute for Healthcare Improvement, addresses
the growing tension betw…
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psnet.ahrq.gov/node/48035/psn-pdf
May 29, 2019 - Is the future of medical diagnosis in computer
algorithms?
May 29, 2019
Gruber K. Is the future of medical diagnosis in computer algorithms? Lancet Digit Health. 2019;1(1):e15-
e16. doi:10.1016/s2589-7500(19)30011-1.
https://psnet.ahrq.gov/issue/future-medical-diagnosis-computer-algorithms
Artificial intelligence…