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psnet.ahrq.gov/node/37406/psn-pdf
March 28, 2012 - Learning from preventable adverse events in health care
organizations: development of a multilevel model of
learning and propositions.
March 28, 2012
Chuang Y-T, Ginsburg LR, Berta WB. Learning from preventable adverse events in health care
organizations: development of a multilevel model of learning and propositi…
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psnet.ahrq.gov/node/46417/psn-pdf
October 11, 2017 - Center for Health Care Human Factors.
October 11, 2017
Armstrong Institute for Patient Safety and Quality.
https://psnet.ahrq.gov/issue/center-health-care-human-factors
Human factors engineering has provided unique insights into designing solutions to address human error
and system weaknesses that facilitate mista…
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psnet.ahrq.gov/node/37326/psn-pdf
January 05, 2012 - Healthy work environments, nurse-physician
communication, and patients' outcomes.
January 5, 2012
Manojlovich M, DeCicco B. Healthy work environments, nurse-physician communication, and patients'
outcomes. Am J Crit Care. 2007;16(6):536-43.
https://psnet.ahrq.gov/issue/healthy-work-environments-nurse-physician-com…
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psnet.ahrq.gov/node/45747/psn-pdf
December 21, 2016 - Implementing No Interruption Zones in the perioperative
environment.
December 21, 2016
Wright I. Implementing No Interruption Zones in the Perioperative Environment. AORN J. 2016;104(6):536-
540. doi:10.1016/j.aorn.2016.09.018.
https://psnet.ahrq.gov/issue/implementing-no-interruption-zones-perioperative-environme…
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psnet.ahrq.gov/node/42981/psn-pdf
March 19, 2014 - Recognizing and managing errors of cognitive
underspecification.
March 19, 2014
Duthie EA. Recognizing and managing errors of cognitive underspecification. J Patient Saf. 2014;10(1):1-5.
doi:10.1097/PTS.0b013e3182a5f6e1.
https://psnet.ahrq.gov/issue/recognizing-and-managing-errors-cognitive-underspecification
Inc…
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psnet.ahrq.gov/node/44279/psn-pdf
August 26, 2015 - Leadership style and patient safety: implications for
nurse managers.
August 26, 2015
Merrill KC. Leadership style and patient safety: implications for nurse managers. J Nurs Adm.
2015;45(6):319-324. doi:10.1097/NNA.0000000000000207.
https://psnet.ahrq.gov/issue/leadership-style-and-patient-safety-implications-nur…
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psnet.ahrq.gov/node/47025/psn-pdf
April 11, 2018 - Chemotherapy medication errors.
April 11, 2018
Weingart SN, Zhang L, Sweeney M, et al. Chemotherapy medication errors. Lancet Oncol.
2018;19(4):e191-e199. doi:10.1016/S1470-2045(18)30094-9.
https://psnet.ahrq.gov/issue/chemotherapy-medication-errors
Chemotherapy errors can result in serious patient harm. This revi…
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psnet.ahrq.gov/node/46382/psn-pdf
December 19, 2017 - Medication errors and trainees: advice for learners and
organizations.
December 19, 2017
Wheeler JS, Duncan R, Hohmeier K. Medication Errors and Trainees: Advice for Learners and
Organizations. Ann Pharmacother. 2017;51(12):1138-1141. doi:10.1177/1060028017725092.
https://psnet.ahrq.gov/issue/medication-errors-and…
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psnet.ahrq.gov/node/844060/psn-pdf
June 01, 2016 - Developing a measure of value in health care.
June 1, 2016
Ken Lee KH, Matthew Austin J, Pronovost PJ. Developing a measure of value in health care. Value Health.
2015;19(4):323-325. doi:10.1016/j.jval.2014.12.009.
https://psnet.ahrq.gov/issue/developing-measure-value-health-care
Value-based healthcare is emerging…
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psnet.ahrq.gov/node/40356/psn-pdf
May 26, 2011 - Clinicians' satisfaction with CPOE ease of use and effect
on clinicians' workflow, efficiency and medication safety.
May 26, 2011
Khajouei R, Wierenga PC, Hasman A, et al. Clinicians satisfaction with CPOE ease of use and effect on
clinicians' workflow, efficiency and medication safety. Int J Med Inform. 2011;80(5)…
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psnet.ahrq.gov/node/46630/psn-pdf
November 15, 2017 - Patient Safety in the Office-Based Practice Setting.
November 15, 2017
Philadelphia, PA: American College of Physicians; 2017.
https://psnet.ahrq.gov/issue/patient-safety-office-based-practice-setting
Patient safety in the ambulatory setting is gaining traction as a focus for research, intervention, and policy.
Th…
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psnet.ahrq.gov/node/47940/psn-pdf
May 01, 2019 - Validation of the Primary Care Patient Measure of Safety
(PC PMOS) questionnaire.
May 1, 2019
Giles SJ, Parveen S, Hernan AL. Validation of the Primary Care Patient Measure of Safety (PC PMOS)
questionnaire. BMJ Qual Saf. 2019;28(5):389-396. doi:10.1136/bmjqs-2018-007988.
https://psnet.ahrq.gov/issue/validation-pr…
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psnet.ahrq.gov/node/39015/psn-pdf
October 14, 2009 - Delays and errors in cardiopulmonary resuscitation and
defibrillation by pediatric residents during simulated
cardiopulmonary arrests.
October 14, 2009
Hunt EA, Vera K, Diener-West M, et al. Delays and errors in cardiopulmonary resuscitation and
defibrillation by pediatric residents during simulated cardiopulmonar…
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psnet.ahrq.gov/node/33962/psn-pdf
June 22, 2007 - Enacting the Washington state patient safety act requiring
hospital staffing plans for nursing services and
establishing recordkeeping and reporting requirements.
June 22, 2007
HB 1602. Washington State Legislature. 2003-2004.
https://psnet.ahrq.gov/issue/enacting-washington-state-patient-safety-act-requiring-hosp…
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psnet.ahrq.gov/node/45051/psn-pdf
May 11, 2016 - Pediatric quality and safety: a nursing perspective.
May 11, 2016
Butler GA, Hupp DS. Pediatric Quality and Safety. Pediatr Clin North Am. 2016;63(2).
doi:10.1016/j.pcl.2015.11.005.
https://psnet.ahrq.gov/issue/pediatric-quality-and-safety-nursing-perspective
Nurses play a key role in ensuring safety, particularly…
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psnet.ahrq.gov/node/44457/psn-pdf
September 29, 2017 - Hospitals slow to adopt patient apology policies.
September 29, 2017
Rice S. Hospitals slow to adopt patient apology policies. Modern healthcare. 2015;45(33):16, 29-30.
https://psnet.ahrq.gov/issue/hospitals-slow-adopt-patient-apology-policies
Communication-and-resolution approaches to medical errors have garnered …
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psnet.ahrq.gov/node/41965/psn-pdf
January 30, 2013 - Vital sign abnormalities, rapid response, and adverse
outcomes in hospitalized patients.
January 30, 2013
Fagan K, Sabel A, Mehler PS, et al. Vital sign abnormalities, rapid response, and adverse outcomes in
hospitalized patients. Am J Med Qual. 2012;27(6):480-6. doi:10.1177/1062860611436127.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/46212/psn-pdf
September 13, 2017 - Improving patient care through improved caregiver
support.
September 13, 2017
Headley M. Patient Saf Qual Healthc. August 21, 2017.
https://psnet.ahrq.gov/issue/improving-patient-care-through-improved-caregiver-support
Health care workers face high levels of stress and production pressures, which can contribute to…
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psnet.ahrq.gov/node/43084/psn-pdf
May 19, 2014 - How can the criminal law support the provision of quality
in healthcare?
May 19, 2014
Yeung K, Horder J. How can the criminal law support the provision of quality in healthcare? BMJ Qual Saf.
2014;23(6):519-24. doi:10.1136/bmjqs-2013-002688.
https://psnet.ahrq.gov/issue/how-can-criminal-law-support-provision-quali…
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psnet.ahrq.gov/node/42774/psn-pdf
May 28, 2015 - Patient safety in plastic surgery: identifying areas for
quality improvement efforts.
May 28, 2015
Hernandez-Boussard T, McDonald KM, Rhoads KF, et al. Patient safety in plastic surgery: identifying areas
for quality improvement efforts. Ann Plast Surg. 2015;74(5):597-602.
doi:10.1097/SAP.0b013e318297791e.
https:…