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psnet.ahrq.gov/issue/accountability-organisational-learning-and-risks-patient-safety-england-conflict-or
December 29, 2014 - Commentary
Accountability, organisational learning and risks to patient safety in England: conflict or compromise?
Citation Text:
Dodds A, Kodate N. Accountability, organisational learning and risks to patient safety in England: Conflict or compromise? Health Risk Soc. 2011;13(4):327-3…
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psnet.ahrq.gov/issue/ozis-and-politics-safety-using-ict-create-regionally-accessible-patient-medication-record
February 04, 2009 - Commentary
OZIS and the politics of safety: using ICT to create a regionally accessible patient medication record.
Citation Text:
Stoop AP, Bal R, Berg M. OZIS and the politics of safety: using ICT to create a regionally accessible patient medication record. Int J Med Inform. 2007;76 S…
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psnet.ahrq.gov/issue/detection-and-measurement-rotator-cuff-tears-sonography-analysis-diagnostic-errors
December 31, 2014 - Study
Detection and measurement of rotator cuff tears with sonography: analysis of diagnostic errors.
Citation Text:
Teefey SA, Middleton WD, Payne WT, et al. Detection and measurement of rotator cuff tears with sonography: analysis of diagnostic errors. AJR Am J Roentgenol. 2005;184(6…
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psnet.ahrq.gov/issue/saying-goodbye
September 11, 2019 - Commentary
Saying goodbye.
Citation Text:
DeFilippis EM. Saying Goodbye. JAMA Intern Med. 2017;177(11):1565. doi:10.1001/jamainternmed.2017.4017.
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Downlo…
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psnet.ahrq.gov/issue/anesthesia-medication-handling-needs-new-vision
July 10, 2017 - Commentary
Anesthesia medication handling needs a new vision.
Citation Text:
Grigg EB, Roesler A. Anesthesia Medication Handling Needs a New Vision. Anesth Analg. 2018;126(1):346-350. doi:10.1213/ANE.0000000000002521.
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psnet.ahrq.gov/issue/information-behavior-context-improving-patient-safety
March 24, 2019 - Commentary
Information behavior in the context of improving patient safety.
Citation Text:
MacIntosh-Murray A, Choo CW. Information behavior in the context of improving patient safety. Journal of the American Society for Information Science and Technology. 2005;56(12). doi:10.1002/asi.…
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psnet.ahrq.gov/issue/satisfaction-intensive-care-unit-nurses-nurse-physician-communication
March 18, 2009 - Study
Satisfaction of intensive care unit nurses with nurse-physician communication.
Citation Text:
Manojlovich M, Antonakos C. Satisfaction of intensive care unit nurses with nurse-physician communication. J Nurs Adm. 2008;38(5):237-43. doi:10.1097/01.NNA.0000312769.19481.18.
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psnet.ahrq.gov/issue/daily-dose-communication-improve-quality-and-safety-outcomes
September 15, 2009 - Review
A daily dose of communication to improve quality and safety outcomes.
Citation Text:
Halm MA. A daily dose of communication to improve quality and safety outcomes. Am J Crit Care. 2024;33(4):305-310. doi:10.4037/ajcc2024318.
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psnet.ahrq.gov/issue/reducing-medication-errors-using-applied-technology
January 07, 2011 - Commentary
Reducing medication errors by using applied technology.
Citation Text:
Caesar BR, Hutchinson B. Reducing medication errors by using applied technology. Nursing (Brux). 2006;36(8):24-25.
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psnet.ahrq.gov/issue/teams-psychologists-helping-teams-evolution-science-team-training
February 26, 2020 - Commentary
Emerging Classic
Teams of psychologists helping teams: the evolution of the science of team training.
Citation Text:
Bisbey TM, Reyes DL, Traylor AM, et al. Teams of psychologists helping teams: The evolution of the science of team training. Am Psycho…
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psnet.ahrq.gov/issue/interventions-improve-teamwork-and-communications-among-healthcare-staff
March 03, 2011 - Review
Interventions to improve teamwork and communications among healthcare staff.
Citation Text:
McCulloch P, Rathbone J, Catchpole K. Interventions to improve teamwork and communications among healthcare staff. Br J Surg. 2011;98(4):469-79. doi:10.1002/bjs.7434.
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psnet.ahrq.gov/issue/innovative-collaborative-model-care-undiagnosed-complex-medical-conditions
November 21, 2021 - Commentary
An innovative collaborative model of care for undiagnosed complex medical conditions.
Citation Text:
Nageswaran S, Donoghue N, Mitchell A, et al. An Innovative Collaborative Model of Care for Undiagnosed Complex Medical Conditions. Pediatrics. 2017;139(5):e20163373. doi:10.154…
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psnet.ahrq.gov/issue/development-training-program-bar-code-assisted-medication-administration-inpatient-pharmacy
September 22, 2021 - Commentary
Development of a training program for bar-code–assisted medication administration in inpatient pharmacy.
Citation Text:
Dartt LR, Schneider R. Development of a training program for bar-code-assisted medication administration in inpatient pharmacy. Am J Health Syst Pharm. 2010…
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psnet.ahrq.gov/issue/understanding-safer-practices-health-care-prologue-role-indicators
May 07, 2008 - Study
Understanding safer practices in health care: a prologue for the role of indicators.
Citation Text:
Kazandjian VA, Wicker K, Ogunbo S, et al. Understanding safer practices in health care: a prologue for the role of indicators. J Eval Clin Pract. 2005;11(2):161-70.
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psnet.ahrq.gov/issue/perspective-beyond-counting-hours-importance-supervision-professionalism-transitions-care-and
September 20, 2011 - Commentary
Perspective: beyond counting hours: the importance of supervision, professionalism, transitions of care, and workload in residency training.
Citation Text:
Schumacher D, Slovin SR, Riebschleger MP, et al. Perspective. Academic Medicine. 2012;87(7). doi:10.1097/acm.0b013e318257…
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psnet.ahrq.gov/issue/shifting-learning-curve
March 09, 2009 - Commentary
Shifting the learning curve.
Citation Text:
Reynolds T, Kong M-L. Shifting the learning curve. BMJ. 2010;341:c6260. doi:10.1136/bmj.c6260.
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psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
February 01, 2017 - We feel that interprofessional education is foundational for improved care coordination and enhanced
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psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
February 01, 2017 - We feel that interprofessional education is foundational for improved care coordination and enhanced
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psnet.ahrq.gov/node/853773/psn-pdf
September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side.
September 27, 2023
Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
The Case
A first-year orthopedic surgery resident was consulted…
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psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
May 01, 2011 - SPOTLIGHT CASE
The Wrong Shot: Error Disclosure
Citation Text:
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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