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psnet.ahrq.gov/node/45365/psn-pdf
August 03, 2016 - Workarounds and test results follow-up in electronic
health record–based primary care.
August 3, 2016
Menon S, Murphy DR, Singh H, et al. Workarounds and Test Results Follow-up in Electronic Health
Record-Based Primary Care. Appl Clin Inform. 2016;7(2):543-559. doi:10.4338/ACI-2015-10-RA-0135.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/44596/psn-pdf
December 04, 2016 - Health literacy in transitions of care: an innovative
objective structured clinical examination for fourth-year
medical students in an internship preparation course.
December 4, 2016
Bloom-Feshbach K, Casey D, Schulson L, et al. Health Literacy in Transitions of Care: An Innovative
Objective Structured Clinical Ex…
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psnet.ahrq.gov/node/47508/psn-pdf
October 24, 2018 - Root cause analysis of reported patient falls in ORs in the
Veterans Health Administration.
October 24, 2018
Soncrant CM, Warner LJ, Neily J, et al. Root Cause Analysis of Reported Patient Falls in ORs in the
Veterans Health Administration. AORN J. 2018;108(4):386-397. doi:10.1002/aorn.12372.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/45484/psn-pdf
December 04, 2016 - High prevalence of medication discrepancies between
home health referrals and Centers for Medicare and
Medicaid Services home health certification and plan of
care and their potential to affect safety of vulnerable
elderly adults.
December 4, 2016
Brody AA, Gibson B, Tresner-Kirsch D, et al. High Prevalence of Me…
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psnet.ahrq.gov/node/44038/psn-pdf
May 06, 2015 - Engineering Patient Safety in Radiation Oncology:
University of North Carolina's Pursuit for High Reliability
and Value Creation.
May 6, 2015
Marks L, Mazur L, Chera B, Adams R. Boca Raton, FL: Productivity Press; 2015. ISBN: 9781482233643.
https://psnet.ahrq.gov/issue/engineering-patient-safety-radiation-oncology…
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psnet.ahrq.gov/node/36348/psn-pdf
March 09, 2009 - Reducing medical error in the Military Health System: how
can team training help?
March 9, 2009
Alonso A, Baker DP, Holtzman A, et al. Reducing medical error in the Military Health System: How can
team training help? Human Resource Management Review. 2006;16(3). doi:10.1016/j.hrmr.2006.05.006.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/47001/psn-pdf
August 17, 2018 - Realist synthesis of intentional rounding in hospital
wards: exploring the evidence of what works, for whom,
in what circumstances and why.
August 17, 2018
Sims S, Leamy M, Davies N, et al. Realist synthesis of intentional rounding in hospital wards: exploring the
evidence of what works, for whom, in what circumst…
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psnet.ahrq.gov/node/46065/psn-pdf
January 01, 2021 - Measurement as a performance driver: the case for a
national measurement system to improve patient safety.
April 26, 2017
Krause TR, Bell KJ, Pronovost P, et al. Measurement as a Performance Driver: The Case for a National
Measurement System to Improve Patient Safety. J Patient Saf. 2021;17(3):e128-e134.
doi:10.10…
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psnet.ahrq.gov/node/46133/psn-pdf
May 24, 2017 - Implementing smart infusion pumps with dose-error
reduction software: real-world experiences.
May 24, 2017
Heron C. Implementing smart infusion pumps with dose-error reduction software: real-world experiences.
Br J Nurs. 2017;26(8):S13-S16. doi:10.12968/bjon.2017.26.8.S13.
https://psnet.ahrq.gov/issue/implementing…
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psnet.ahrq.gov/node/45013/psn-pdf
April 13, 2016 - Good Practice Guides on Medication Errors: Part 1 and
Part 2.
April 13, 2016
Goedecke T, Ord K, Newbould V, et al. Medication Errors: New Eu Good Practice Guide On Risk
Minimisation And Error Prevention. Springer Science and Business Media LLC; 2016. doi:10.1007/s40264-
016-0410-4.
https://psnet.ahrq.gov/issue/go…
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psnet.ahrq.gov/node/47523/psn-pdf
December 05, 2018 - Developing standardized "receiver-driven" handoffs
between referring providers and the emergency
department: results of a multidisciplinary needs
assessment.
December 5, 2018
Huth K, Stack AM, Chi G, et al. Developing Standardized "Receiver-Driven" Handoffs Between Referring
Providers and the Emergency Department…
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psnet.ahrq.gov/node/34694/psn-pdf
February 10, 2011 - Computerized surveillance of adverse drug events in
hospital patients.
February 10, 2011
Classen DC, Pestotnik SL, Evans RS, et al. Computerized surveillance of adverse drug events in hospital
patients. JAMA. 1991;266(20):2847-51.
https://psnet.ahrq.gov/issue/computerized-surveillance-adverse-drug-events-hospital-…
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psnet.ahrq.gov/node/43141/psn-pdf
April 30, 2014 - Engaging residents and fellows to improve institution-
wide quality: the first six years of a novel financial
incentive program.
April 30, 2014
Vidyarthi A, Green AL, Rosenbluth G, et al. Engaging residents and fellows to improve institution-wide
quality: the first six years of a novel financial incentive program.…
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psnet.ahrq.gov/node/45594/psn-pdf
December 19, 2017 - Teaching quality improvement and patient safety in
residency education: strategies for meaningful resident
quality and safety initiatives.
December 19, 2017
Morrison RJ, Bowe SN, Brenner MJ. Teaching Quality Improvement and Patient Safety in Residency
Education: Strategies for Meaningful Resident Quality and Safet…
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psnet.ahrq.gov/node/47083/psn-pdf
June 21, 2018 - Accuracy of skin cancer diagnosis by physician
assistants compared with dermatologists in a large health
care system.
June 21, 2018
Anderson AM, Matsumoto M, Saul MI, et al. Accuracy of Skin Cancer Diagnosis by Physician Assistants
Compared With Dermatologists in a Large Health Care System. JAMA Dermatol. 2018;154…
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psnet.ahrq.gov/node/45340/psn-pdf
August 17, 2016 - To the point: integrating patient safety education Into the
obstetrics and gynecology undergraduate curriculum.
August 17, 2016
Abbott JF, Pradhan A, Buery-Joyner S, et al. To the Point: Integrating Patient Safety Education Into the
Obstetrics and Gynecology Undergraduate Curriculum. J Patient Saf. 2016;16(1):e39-e…
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psnet.ahrq.gov/node/46631/psn-pdf
March 20, 2018 - Simulation-based education to ensure provider
competency within the healthcare system.
March 20, 2018
Griswold S, Fralliccardi A, Boulet J, et al. Simulation-based Education to Ensure Provider Competency
Within the Health Care System. Acad Emerg Med. 2018;25(2):168-176. doi:10.1111/acem.13322.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/46835/psn-pdf
February 28, 2018 - Errors detected in pediatric oral liquid medication doses
prepared in an automated workflow management system.
February 28, 2018
Bledsoe S, Van Buskirk A, Falconer J, et al. Errors detected in pediatric oral liquid medication doses
prepared in an automated workflow management system. Am J Health Syst Pharm. 2018;75…
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psnet.ahrq.gov/node/46905/psn-pdf
October 13, 2018 - Association of hospital participation in a regional trauma
quality improvement collaborative with patient outcomes.
October 13, 2018
Hemmila MR, Cain-Nielsen AH, Jakubus JL, et al. Association of Hospital Participation in a Regional
Trauma Quality Improvement Collaborative With Patient Outcomes. JAMA Surg. 2018;153…
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psnet.ahrq.gov/node/60522/psn-pdf
May 27, 2020 - Nursing turbulence in critical care: relationships with
nursing workload and patient safety.
May 27, 2020
Browne J, Braden CJ. Nursing turbulence in critical care: relationships with nursing workload and patient
safety. Am J Crit Care. 2020;29(3):182-191. doi:10.4037/ajcc2020180.
https://psnet.ahrq.gov/issue/nursi…