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psnet.ahrq.gov/node/45364/psn-pdf
September 04, 2016 - A piece of my mind. Changing the narrative.
September 4, 2016
Allen-Dicker J. Changing the Narrative. JAMA. 2016;316(3). doi:10.1001/jama.2016.3029.
https://psnet.ahrq.gov/issue/piece-my-mind-changing-narrative
Storytelling can share knowledge and build community among physicians. However, if clinicians
communicat…
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psnet.ahrq.gov/node/45749/psn-pdf
January 11, 2017 - Instrument count sheets and set reviews as patient safety
tools.
January 11, 2017
Spear J. Instrument Count Sheets and Set Reviews as Patient Safety Tools. AORN J. 2016;104(6):588-
592. doi:10.1016/j.aorn.2016.10.007.
https://psnet.ahrq.gov/issue/instrument-count-sheets-and-set-reviews-patient-safety-tools
Inaccu…
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psnet.ahrq.gov/node/46460/psn-pdf
January 17, 2018 - Association between organisational and workplace
cultures, and patient outcomes: systematic review.
January 17, 2018
Braithwaite J, Herkes J, Ludlow K, et al. Association between organisational and workplace cultures, and
patient outcomes: systematic review. BMJ Open. 2017;7(11). doi:10.1136/bmjopen-2017-017708.
h…
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psnet.ahrq.gov/node/47708/psn-pdf
February 13, 2019 - The role of purple pens in learning to prescribe.
February 13, 2019
Kinston R, McCarville N, Hassell A. The role of purple pens in learning to prescribe. Clin Teach.
2019;16(6):598-603. doi:10.1111/tct.12991.
https://psnet.ahrq.gov/issue/role-purple-pens-learning-prescribe
Interventions utilizing color as visual c…
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psnet.ahrq.gov/node/47414/psn-pdf
May 01, 2019 - Impact of teamwork improvement training on
communication and teamwork climate in ambulatory
reproductive health care.
May 1, 2019
Dodge LE, Nippita S, Hacker MR, et al. Impact of teamwork improvement training on communication and
teamwork climate in ambulatory reproductive health care. J Healthc Risk Manag. 2019;3…
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psnet.ahrq.gov/node/46444/psn-pdf
December 19, 2017 - Nil per os orders for imaging: a teachable moment.
December 19, 2017
Wickerham AL, Schultz EJ, Lewine EB. Nil per Os Orders for Imaging: A Teachable Moment. JAMA Intern
Med. 2017;177(11):1670-1671. doi:10.1001/jamainternmed.2017.3943.
https://psnet.ahrq.gov/issue/nil-os-orders-imaging-teachable-moment
Patients are…
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psnet.ahrq.gov/node/45160/psn-pdf
May 18, 2016 - Clues to better health care from old malpractice lawsuits.
May 18, 2016
Landro L.
https://psnet.ahrq.gov/issue/clues-better-health-care-old-malpractice-lawsuits
Closed claims have been considered a source for adverse event data for years, and recently such data has
been utilized to inform safety improvement work. …
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psnet.ahrq.gov/node/47358/psn-pdf
August 29, 2018 - Double reading in breast cancer screening: cohort
evaluation in the CO-OPS trial.
August 29, 2018
Taylor-Phillips S, Jenkinson D, Stinton C, et al. Double Reading in Breast Cancer Screening: Cohort
Evaluation in the CO-OPS Trial. Radiology. 2018;287(3):749-757. doi:10.1148/radiol.2018171010.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/46253/psn-pdf
August 28, 2017 - Diagnostic stewardship—leveraging the laboratory to
improve antimicrobial use.
August 28, 2017
Morgan DJ, Malani P, Diekema DJ. Diagnostic Stewardship-Leveraging the Laboratory to Improve
Antimicrobial Use. JAMA. 2017;318(7):607-608. doi:10.1001/jama.2017.8531.
https://psnet.ahrq.gov/issue/diagnostic-stewardship-l…
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psnet.ahrq.gov/node/43126/psn-pdf
April 23, 2014 - Safe and appropriate use of insulin and other
antihyperglycemic agents in hospital.
April 23, 2014
Cornish W. Safe and appropriate use of insulin and other antihyperglycemic agents in hospital. Can J
Diabetes. 2014;38(2):94-100. doi:10.1016/j.jcjd.2014.01.002.
https://psnet.ahrq.gov/issue/safe-and-appropriate-use-…
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psnet.ahrq.gov/node/46714/psn-pdf
January 10, 2018 - A system-based approach to managing patient safety in
ambulatory care (and beyond).
January 10, 2018
Burger C, Eaton P, Hess K, et al. Patient Saf Qual Healthc. December 12, 2017.
https://psnet.ahrq.gov/issue/system-based-approach-managing-patient-safety-ambulatory-care-and-beyond
Systems-based improvements are ke…
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psnet.ahrq.gov/node/43321/psn-pdf
August 02, 2015 - Costs associated with surgical site infections in Veterans
Affairs hospitals.
August 2, 2015
Schweizer ML, Cullen JJ, Perencevich E, et al. Costs Associated With Surgical Site Infections in Veterans
Affairs Hospitals. JAMA Surg. 2014;149(6):575-81. doi:10.1001/jamasurg.2013.4663.
https://psnet.ahrq.gov/issue/costs…
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psnet.ahrq.gov/node/72761/psn-pdf
February 17, 2021 - Using ventilator splitters during the COVID-19 pandemic--
letter to health care providers.
February 17, 2021
Silver Spring, MD: Division of Industry and Consumer Education, US Food and Drug Administration;
February 9. 2021.
https://psnet.ahrq.gov/issue/using-ventilator-splitters-during-covid-19-pandemic-letter-hea…
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psnet.ahrq.gov/node/60766/psn-pdf
August 05, 2020 - Dermatology faces a reckoning: lack of darker skin in
textbooks and journals harms care for patients of color.
August 5, 2020
McFarling UL. Stat. July 21, 2020.
https://psnet.ahrq.gov/issue/dermatology-faces-reckoning-lack-darker-skin-textbooks-and-journals-harms-
care-patients-color
Dermatologists rely on v…
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psnet.ahrq.gov/node/42135/psn-pdf
April 22, 2013 - Interprofessional education in team communication:
working together to improve patient safety.
April 22, 2013
Brock DM, Abu-Rish E, Chiu C-R, et al. Interprofessional education in team communication: working
together to improve patient safety. BMJ Qual Saf. 2013;22(5):414-23. doi:10.1136/bmjqs-2012-000952.
https:/…
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psnet.ahrq.gov/node/45547/psn-pdf
October 05, 2016 - Sick children face potentially deadly danger: medication
errors.
October 5, 2016
Furfaro H. Wall Street Journal. September 25, 2016.
https://psnet.ahrq.gov/issue/sick-children-face-potentially-deadly-danger-medication-errors
Medication errors in pediatric care are common in the hospital and at home. This newspaper…
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psnet.ahrq.gov/node/39197/psn-pdf
January 06, 2010 - root-cause-analysis
https://psnet.ahrq.gov/primer/never-events
https://psnet.ahrq.gov/issue/resident-duty-hours-enhancing-sleep-supervision-and-safety
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psnet.ahrq.gov/node/43027/psn-pdf
July 23, 2014 - improving-team-information-sharing-structured-call-out-anaesthetic-emergencies-randomized
https://psnet.ahrq.gov/issue/enhancing-patient-safety-during-hand-offs-standardized-communication-and-teamwork-using-sbar
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psnet.ahrq.gov/node/44513/psn-pdf
September 23, 2015 - recommendations to improve diagnosis, including promoting teamwork among interdisciplinary health care
teams, enhancing
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psnet.ahrq.gov/node/47516/psn-pdf
December 19, 2018 - Diverse stakeholders in Australia established an agenda for enhancing test result management,
which