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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/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/43761/psn-pdf
July 01, 2016 - An electronic checklist improves transfer and retention of
critical information at intraoperative handoff of care.
July 1, 2016
Agarwala A, Firth PG, Albrecht MA, et al. An electronic checklist improves transfer and retention of critical
information at intraoperative handoff of care. Anesth Analg. 2015;120(1):96-10…
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psnet.ahrq.gov/node/46736/psn-pdf
December 17, 2018 - Back to basics: the Universal Protocol.
December 17, 2018
Spruce L. Back to Basics: The Universal Protocol: 1.4 www.aornjournal.org/content/cme. AORN J.
2018;107(1):116-125. doi:10.1002/aorn.12002.
https://psnet.ahrq.gov/issue/back-basics-universal-protocol
Wrong-site, wrong-procedure, and wrong-patient errors are…
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psnet.ahrq.gov/node/846168/psn-pdf
March 15, 2023 - Now is the time to routinely ask patients about safety.
March 15, 2023
Gandhi TK. Now Is the Time to Routinely Ask Patients About Safety. Jt Comm J Qual Patient Saf.
2023;49(4):235-236. doi:10.1016/j.jcjq.2023.01.009.
https://psnet.ahrq.gov/issue/now-time-routinely-ask-patients-about-safety
Safety event reporting …
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psnet.ahrq.gov/node/47085/psn-pdf
June 06, 2018 - Medical Device Safety Action Plan: Protecting Patients,
Promoting Public Health.
June 6, 2018
Silver Spring, MD: US Food and Drug Administration; April 2018.
https://psnet.ahrq.gov/issue/medical-device-safety-action-plan-protecting-patients-promoting-public-health
Reliable use of medical devices is an important co…
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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/46244/psn-pdf
June 28, 2017 - Changing the narratives for patient safety.
June 28, 2017
Pronovost P, Sutcliffe K, Basu L, et al. Changing the narratives for patient safety. Bull World Health Organ.
2017;95(6):478-480. doi:10.2471/BLT.16.178392.
https://psnet.ahrq.gov/issue/changing-narratives-patient-safety
Mental models represent established …
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psnet.ahrq.gov/node/45986/psn-pdf
March 29, 2017 - Pediatric prehospital medication dosing errors: a national
survey of paramedics.
March 29, 2017
Hoyle JD, Crowe RP, Bentley MA, et al. Pediatric prehospital medication dosing errors: a national survey of
paramedics. Prehosp Emerg Care. 2017;21(2):185-191. doi:10.1080/10903127.2016.1227001.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/44445/psn-pdf
September 16, 2015 - Understanding nurses' and physicians' fear of
repercussions for reporting errors: clinician
characteristics, organization demographics, or leadership
factors?
September 16, 2015
Castel ES, Ginsburg LR, Zaheer S, et al. Understanding nurses' and physicians' fear of repercussions for
reporting errors: clinician cha…
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psnet.ahrq.gov/node/40758/psn-pdf
September 07, 2011 - A review of educational strategies to improve nurses'
roles in recognizing and responding to deteriorating
patients.
September 7, 2011
Liaw SY, Scherpbier A, Klainin-Yobas P, et al. A review of educational strategies to improve nurses' roles
in recognizing and responding to deteriorating patients. Int Nurs Rev. 20…
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psnet.ahrq.gov/node/854252/psn-pdf
October 04, 2023 - Standardization and visualization of the surgical time-out.
October 4, 2023
Levy BE, Wilt WS, Lantz S, et al. Standardization and visualization of the surgical time-out. J Patient Saf.
2023;19(7):453-459. doi:10.1097/pts.0000000000001156.
https://psnet.ahrq.gov/issue/standardization-and-visualization-surgical-time-…
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psnet.ahrq.gov/node/42893/psn-pdf
March 13, 2014 - Effect of patient safety strategies on the incidence of
adverse events.
March 13, 2014
Sierra AF, del Aguila del MR, Espigares JLN, et al. Effect of patient safety strategies on the incidence of
adverse events. J Eval Clin Pract. 2014;20(2):184-90. doi:10.1111/jep.12105.
https://psnet.ahrq.gov/issue/effect-patient…
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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/48185/psn-pdf
August 28, 2019 - Addressing the elephant in the room: a shame resilience
seminar for medical students.
August 28, 2019
Bynum WE, Adams A, Edelman CE, et al. Addressing the Elephant in the Room: A Shame Resilience
Seminar for Medical Students. Acad Med. 2019;94(8):1132-1136. doi:10.1097/ACM.0000000000002646.
https://psnet.ahrq.gov/…
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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/46080/psn-pdf
August 28, 2017 - A growth mindset approach to preparing trainees for
medical error.
August 28, 2017
Klein J, Delany C, Fischer MD, et al. A growth mindset approach to preparing trainees for medical error.
BMJ Qual Saf. 2017;26(9):771-774. doi:10.1136/bmjqs-2016-006416.
https://psnet.ahrq.gov/issue/growth-mindset-approach-preparing…
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psnet.ahrq.gov/node/37259/psn-pdf
March 23, 2011 - Using a survey of incident reporting and learning
practices to improve organisational learning at a cancer
care centre.
March 23, 2011
Cooke DL, Dunscombe PB, Lee R. Using a survey of incident reporting and learning practices to improve
organisational learning at a cancer care centre. Qual Saf Health Care. 2007;16…