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psnet.ahrq.gov/node/46076/psn-pdf
September 24, 2017 - The evolving story of overlapping surgery.
September 24, 2017
Mello MM, Livingston EH. The Evolving Story of Overlapping Surgery. JAMA. 2017;318(3):233-234.
doi:10.1001/jama.2017.8061.
https://psnet.ahrq.gov/issue/evolving-story-overlapping-surgery
Scheduling overlapping procedures is perceived as risky, despite l…
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psnet.ahrq.gov/node/39072/psn-pdf
November 04, 2009 - Variations in nursing care quality across hospitals.
November 4, 2009
Lucero RJ, Lake ET, Aiken LH. Variations in nursing care quality across hospitals. J Adv Nurs.
2009;65(11):2299-310. doi:10.1111/j.1365-2648.2009.05090.x.
https://psnet.ahrq.gov/issue/variations-nursing-care-quality-across-hospitals
This seconda…
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psnet.ahrq.gov/node/45689/psn-pdf
January 25, 2018 - How to prevent burnout (maybe).
January 25, 2018
Dissanaike S. How to prevent burnout (maybe). Am J Surg. 2016;212(6):1251-1255.
doi:10.1016/j.amjsurg.2016.08.022.
https://psnet.ahrq.gov/issue/how-prevent-burnout-maybe
Burnout can affect the ability of individuals and teams to act safely. Originally delivered as a…
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psnet.ahrq.gov/node/44729/psn-pdf
January 07, 2016 - The morbidity and mortality meeting: time for a different
approach?
January 7, 2016
Fraser J. The morbidity and mortality meeting: time for a different approach? Arch Dis Child. 2016;101(1):4-
8. doi:10.1136/archdischild-2015-309536.
https://psnet.ahrq.gov/issue/morbidity-and-mortality-meeting-time-different-appro…
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psnet.ahrq.gov/node/45564/psn-pdf
October 03, 2017 - Fostering transparency in outcomes, quality, safety, and
costs.
October 3, 2017
Austin M, McGlynn EA, Pronovost P. Fostering Transparency in Outcomes, Quality, Safety, and Costs.
JAMA. 2016;316(16):1661-1662. doi:10.1001/jama.2016.14039.
https://psnet.ahrq.gov/issue/fostering-transparency-outcomes-quality-safety-a…
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psnet.ahrq.gov/node/34715/psn-pdf
February 18, 2011 - Continuous improvement as an ideal in health care.
February 18, 2011
Berwick D. Continuous improvement as an ideal in health care. New Engl J Med. 1989;320(1):53-56.
https://psnet.ahrq.gov/issue/continuous-improvement-ideal-health-care
Two approaches to improving quality in health care are illustrated in this artic…
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psnet.ahrq.gov/node/43945/psn-pdf
September 09, 2015 - Hospital and procedure incidence of pediatric retained
surgical items.
September 9, 2015
Wang B, Tashiro J, Perez EA, et al. Hospital and procedure incidence of pediatric retained surgical items. J
Surg Res. 2015;198(2):400-5. doi:10.1016/j.jss.2015.03.054.
https://psnet.ahrq.gov/issue/hospital-and-procedure-incid…
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psnet.ahrq.gov/node/44682/psn-pdf
March 15, 2016 - On resident duty hour restrictions and neurosurgical
training: review of the literature.
March 15, 2016
Bina RW, Lemole M, Dumont TM. On resident duty hour restrictions and neurosurgical training: review of
the literature. J Neurosurg. 2016;124(3):842-8. doi:10.3171/2015.3.JNS142796.
https://psnet.ahrq.gov/issue/r…
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psnet.ahrq.gov/node/45232/psn-pdf
August 10, 2016 - Promoting patient safety with perioperative hand-off
communication.
August 10, 2016
Robinson NL. Promoting Patient Safety With Perioperative Hand-off Communication. J Perianesth Nurs.
2016;31(3):245-53. doi:10.1016/j.jopan.2014.08.144.
https://psnet.ahrq.gov/issue/promoting-patient-safety-perioperative-hand-commun…
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psnet.ahrq.gov/node/47213/psn-pdf
June 20, 2018 - Are second victims getting the help they need?
June 20, 2018
Headley M. Patient Saf Qual Healthc. May/June 2018.
https://psnet.ahrq.gov/issue/are-second-victims-getting-help-they-need
Clinicians can experience emotional stress, guilt, and insecurity after making a mistake. Organizations are
increasingly building p…
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psnet.ahrq.gov/node/46360/psn-pdf
October 25, 2017 - Creating a culture of caregiver support.
October 25, 2017
Gold KJ, Andrew LB, Goldman EB, et al. “I would never want to have a mental health diagnosis on my
record”: A survey of female physicians on mental health diagnosis, treatment, and reporting. General
Hospital Psychiatry. 2016;43. doi:10.1016/j.genhosppsych.2…
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psnet.ahrq.gov/node/40643/psn-pdf
July 27, 2011 - Does the implementation of an electronic prescribing
system create unintended medication errors? A study of
the sociotechnical context through the analysis of
reported medication incidents.
July 27, 2011
Redwood S, Rajakumar A, Hodson J, et al. Does the implementation of an electronic prescribing system
create un…
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psnet.ahrq.gov/node/43030/psn-pdf
March 26, 2014 - Recommendations for practitioners and manufacturers to
address system-based causes of vaccine errors.
March 26, 2014
ISMP Medication Safety Alert! Acute care edition. March 13, 2014;19:1-2,4-5.
https://psnet.ahrq.gov/issue/recommendations-practitioners-and-manufacturers-address-system-based-
causes-vaccine-…
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psnet.ahrq.gov/node/46457/psn-pdf
December 20, 2017 - Simulation and the diagnostic process: a pilot study of
trauma and rapid response teams.
December 20, 2017
Juriga LL, Murray DJ, Boulet JR, et al. Simulation and the diagnostic process: a pilot study of trauma and
rapid response teams. Diagnosis (Berl). 2017;4(4):241-249. doi:10.1515/dx-2017-0010.
https://psnet.ah…
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psnet.ahrq.gov/node/39972/psn-pdf
January 22, 2017 - Executive/senior leader checklist to improve culture and
reduce central line–associated bloodstream infections.
January 22, 2017
Goeschel CA, Holzmueller CG, Berenholtz SM, et al. Executive/Senior Leader Checklist to improve culture
and reduce central line-associated bloodstream infections. Jt Comm J Qual Patient S…
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psnet.ahrq.gov/node/46895/psn-pdf
March 14, 2018 - Rapid response teams: what's the latest?
March 14, 2018
Jackson SA. Rapid response teams: What's the latest? Nursing (Brux). 2017;47(12):34-41.
doi:10.1097/01.NURSE.0000526885.10306.21.
https://psnet.ahrq.gov/issue/rapid-response-teams-whats-latest
Rapid response systems are an established strategy to prevent in-h…
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psnet.ahrq.gov/web-mm/stroke-error
February 01, 2016 - SPOTLIGHT CASE
A Stroke of Error
Citation Text:
Barrett KM. A Stroke of Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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Format:
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psnet.ahrq.gov/node/39309/psn-pdf
December 09, 2014 - Patient Safety in Emergency Medicine.
December 9, 2014
Croskerry P, Cosby KS, Schenkel SM, Wears RL, eds. Philadelphia, PA: Lippincott Williams & Wilkins;
2009. ISBN: 9780781777278.
https://psnet.ahrq.gov/issue/patient-safety-emergency-medicine
The pace, diversity, and scope of an emergency department (ED) cre…
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psnet.ahrq.gov/node/43645/psn-pdf
November 12, 2014 - Health IT and Clinical Decision Support Systems.
November 12, 2014
Ohno-Machado L, ed. J Am Med Inform Assoc. 2014;21:e180-e375.
https://psnet.ahrq.gov/issue/health-it-and-clinical-decision-support-systems
A universal agreement on how to calculate the return on investment for health information technology (IT)
and…
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psnet.ahrq.gov/node/44691/psn-pdf
December 02, 2015 - Quality and safety in orthopaedics: learning and teaching
at the same time: AOA critical issues.
December 2, 2015
Black KP, Armstrong AD, Hutzler L, et al. Quality and Safety in Orthopaedics: Learning and Teaching at the
Same Time: AOA Critical Issues. J Bone Joint Surg Am. 2015;97(21):1809-15. doi:10.2106/JBJS.O.0…