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psnet.ahrq.gov/node/44348/psn-pdf
September 04, 2016 - Examining the attitudes of hospital pharmacists to
reporting medication safety incidents using the theory of
planned behaviour.
September 4, 2016
Williams SD, Phipps D, Ashcroft DM. Examining the attitudes of hospital pharmacists to reporting
medication safety incidents using the theory of planned behaviour. Int J…
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psnet.ahrq.gov/node/73170/psn-pdf
April 21, 2021 - Sentinel Event Alert 63: optimizing smart infusion pump
safety with DERS.
April 21, 2021
Sentinel Event Alert 63: Optimizing Smart Infusion Pump Safety with DERS. Jt Comm J Qual Patient Saf.
2021;47(6):394-397. doi:10.1016/j.jcjq.2021.03.013.
https://psnet.ahrq.gov/issue/sentinel-event-alert-63-optimizing-smart-in…
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psnet.ahrq.gov/node/74721/psn-pdf
February 02, 2022 - Hospital at Home: setting a regulatory course to ensure
safe, high-quality care.
February 2, 2022
DeCherrie LV, Leff B, Levine DM, et al. Hospital at Home: setting a regulatory course to ensure safe, high-
quality care. Jt Comm J Qual Patient Saf. 2022;48(3):180-184. doi:10.1016/j.jcjq.2021.12.003.
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psnet.ahrq.gov/node/44836/psn-pdf
January 27, 2016 - Advancing the next generation of handover research and
practice with cognitive load theory.
January 27, 2016
Young JQ, Wachter R, Cate OT, et al. Advancing the next generation of handover research and practice
with cognitive load theory. BMJ Qual Saf. 2016;25(2):66-70. doi:10.1136/bmjqs-2015-004181.
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January 01, 2021 - 30-day potentially avoidable readmissions due to adverse
drug events.
May 3, 2017
Dalleur O, Beeler PE, Schnipper JL, et al. 30-Day Potentially Avoidable Readmissions Due to Adverse
Drug Events. J Patient Saf. 2021;17(5):e379-e386. doi:10.1097/pts.0000000000000346.
https://psnet.ahrq.gov/issue/30-day-potentially-a…
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psnet.ahrq.gov/node/39334/psn-pdf
March 03, 2010 - The impact of prolonged continuous wakefulness on
resident clinical performance in the intensive care unit: a
patient simulator study.
March 3, 2010
Sharpe R, Koval V, Ronco JJ, et al. The impact of prolonged continuous wakefulness on resident clinical
performance in the intensive care unit: a patient simulator st…
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psnet.ahrq.gov/node/47274/psn-pdf
November 21, 2018 - Developing a hospital-wide quality and safety dashboard:
a qualitative research study.
November 21, 2018
Weggelaar-Jansen AMJWM, Broekharst DSE, de Bruijne M. Developing a hospital-wide quality and safety
dashboard: a qualitative research study. BMJ Qual Saf. 2018;27(12):1000-1007. doi:10.1136/bmjqs-2018-
007784.
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March 14, 2018 - Engaging the front line: tapping into hospital-wide quality
and safety initiatives.
March 14, 2018
Wolpaw J, Schwengel D, Hensley N, et al. Engaging the Front Line: Tapping into Hospital-Wide Quality
and Safety Initiatives. J Cardiothorac Vasc Anesth. 2018;32(1):522-533. doi:10.1053/j.jvca.2017.05.038.
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June 27, 2018 - Drug shortages roundtable: minimizing the impact on
patient care.
June 27, 2018
Drug shortages roundtable: Minimizing the impact on patient care. Am J Health Syst Pharm.
2018;75(11):816-820. doi:10.2146/ajhp180048.
https://psnet.ahrq.gov/issue/drug-shortages-roundtable-minimizing-impact-patient-care
This commenta…
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psnet.ahrq.gov/node/44080/psn-pdf
September 27, 2017 - A descriptive study of nurse-reported missed care in
neonatal intensive care units.
September 27, 2017
Tubbs-Cooley HL, Pickler RH, Younger JB, et al. A descriptive study of nurse-reported missed care in
neonatal intensive care units. J Adv Nurs. 2015;71(4):813-24. doi:10.1111/jan.12578.
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psnet.ahrq.gov/node/44735/psn-pdf
January 06, 2016 - Quality and patient safety teams in the perioperative
setting.
January 6, 2016
Serino MF. Quality and Patient Safety Teams in the Perioperative Setting. AORN J. 2015;102(6):617-28.
doi:10.1016/j.aorn.2015.10.006.
https://psnet.ahrq.gov/issue/quality-and-patient-safety-teams-perioperative-setting
Team effectivenes…
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psnet.ahrq.gov/node/45271/psn-pdf
August 10, 2016 - Patient identification and tube labelling—a call for
harmonisation.
August 10, 2016
van Dongen-Lases EC, Cornes MP, Grankvist K, et al. Patient identification and tube labelling – a call for
harmonisation. Clinical Chemistry and Laboratory Medicine (CCLM). 2016;54(7). doi:10.1515/cclm-2015-
1089.
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September 16, 2015 - Color-coded prefilled medication syringes decrease time
to delivery and dosing errors in simulated prehospital
pediatric resuscitations: a randomized crossover trial.
September 16, 2015
Stevens AD, Hernandez C, Jones S, et al. Color-coded prefilled medication syringes decrease time to
delivery and dosing errors in…
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psnet.ahrq.gov/node/47724/psn-pdf
March 20, 2019 - Understanding patient safety and quality outcome data.
March 20, 2019
Easter K, Tamburri LM. Understanding Patient Safety and Quality Outcome Data. Crit Care Nurse.
2018;38(6):58-66. doi:10.4037/ccn2018979.
https://psnet.ahrq.gov/issue/understanding-patient-safety-and-quality-outcome-data
Public reporting of safet…
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psnet.ahrq.gov/node/73575/psn-pdf
August 04, 2021 - Unlocking Solutions in Imaging: Working Together to
Learn from Failings in the NHS.
August 4, 2021
Manchester, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016.
https://psnet.ahrq.gov/issue/unlocking-solutions-imaging-working-together-learn-failings-nhs
Lack of appropriate follow up o…
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psnet.ahrq.gov/node/47205/psn-pdf
July 25, 2018 - Teamwork and Teamwork Training in Healthcare.
July 25, 2018
Teamwork and Teamwork Training in Health care: An Integration and a Path Forward. Buljac-Samardzic M,
Dekker-van Doorn C, Maynard MT, eds. Group Org Manag. 2018;43(3):351-527.
doi:10.1177/1059601118774669.
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psnet.ahrq.gov/node/847726/psn-pdf
January 01, 2024 - Systematic review of clinical debriefing tools: attributes
and evidence for use.
April 19, 2023
Phillips EC, Smith SE, Tallentire VR, et al. Systematic review of clinical debriefing tools: attributes and
evidence for use. BMJ Qual Saf. 2024;33(3):187-198. doi:10.1136/bmjqs-2022-015464.
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May 11, 2016 - Promoting patient safety: results of a TeamSTEPPS
initiative.
May 11, 2016
Gaston T, Short N, Ralyea C, et al. Promoting patient safety: results of a TeamSTEPPS initiative. J Nurs
Adm. 2016;46(4):201-207. doi:10.1097/nna.0000000000000333.
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September 29, 2018 - Using clinical simulation to study how to improve quality
and safety in healthcare.
September 29, 2018
Lamé G, Dixon-Woods M. Using clinical simulation to study how to improve quality and safety in
healthcare. BMJ Simul Technol Enhanc Learn. 2018;6(2):87-94. doi:10.1136/bmjstel-2018-000370.
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December 19, 2017 - Characteristics associated with requests by pathologists
for second opinions on breast biopsies.
December 19, 2017
Geller BM, Nelson HD, Weaver DL, et al. Characteristics associated with requests by pathologists for
second opinions on breast biopsies. J Clin Pathol. 2017;70(11):947-953. doi:10.1136/jclinpath-2016-
…