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psnet.ahrq.gov/node/45124/psn-pdf
June 22, 2016 - The impact of surgical safety checklists on theatre
departments: a critical review of the literature.
June 22, 2016
Cadman V. The impact of surgical safety checklists on theatre departments: a critical review of the
literature. J Perioper Pract. 2016;26(4):62-71.
https://psnet.ahrq.gov/issue/impact-surgical-safety…
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psnet.ahrq.gov/node/45886/psn-pdf
July 05, 2017 - Organizational perspectives of nurse executives in 15
hospitals on the impact and effectiveness of rapid
response teams.
July 5, 2017
Smith PL, McSweeney J. Organizational Perspectives of Nurse Executives in 15 Hospitals on the Impact
and Effectiveness of Rapid Response Teams. Jt Comm J Qual Patient Saf. 2017;43(6…
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psnet.ahrq.gov/node/836917/psn-pdf
April 13, 2022 - Error and cognitive bias in diagnostic radiology.
April 13, 2022
Tee QX, Nambiar M, Stuckey S. Error and cognitive bias in diagnostic radiology. J Med Imaging Radiat
Oncol. 2022;66(2):202-207. doi:10.1111/1754-9485.13320.
https://psnet.ahrq.gov/issue/error-and-cognitive-bias-diagnostic-radiology
Diagnostic errors …
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psnet.ahrq.gov/node/44872/psn-pdf
February 12, 2016 - Reducing preventable harm in hospitals.
February 12, 2016
Bornstein D. New York Times. January 26, and February 2, 2016.
https://psnet.ahrq.gov/issue/reducing-preventable-harm-hospitals
Discussing the importance of designing safeguards to prevent system failures that can result in patient
harm, this two-part newsp…
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psnet.ahrq.gov/node/867136/psn-pdf
November 13, 2024 - Detecting clinical medication errors with AI enabled
wearable cameras.
November 13, 2024
Chan J, Nsumba S, Wortsman M, et al. Detecting clinical medication errors with AI enabled wearable
cameras. NPJ Dig Med. 2024;7(1):287. doi:10.1038/s41746-024-01295-2.
https://psnet.ahrq.gov/issue/detecting-clinical-medication…
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psnet.ahrq.gov/node/46808/psn-pdf
February 14, 2018 - Anesthesia medication handling needs a new vision.
February 14, 2018
Grigg EB, Roesler A. Anesthesia Medication Handling Needs a New Vision. Anesth Analg.
2018;126(1):346-350. doi:10.1213/ANE.0000000000002521.
https://psnet.ahrq.gov/issue/anesthesia-medication-handling-needs-new-vision
Anesthesiology has been a le…
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psnet.ahrq.gov/node/34812/psn-pdf
March 05, 2008 - The critical incident technique.
March 5, 2008
FLANAGAN JC. The critical incident technique. Psychol Bull. 1954;51(4):327-358.
https://psnet.ahrq.gov/issue/critical-incident-technique
This review details the background of a methodology aimed to record specific behaviors, rather than
opinions or estimates, in evalu…
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psnet.ahrq.gov/node/72584/psn-pdf
December 16, 2020 - Hidden medication loss when using a primary
administration set for small-volume intermittent infusions.
December 16, 2020
ISMP Medication Safety Alert! Acute care edition. December 3, 2020;25(24).
https://psnet.ahrq.gov/issue/hidden-medication-loss-when-using-primary-administration-set-small-volume-
intermittent
…
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psnet.ahrq.gov/node/46216/psn-pdf
July 12, 2017 - Physician satisfaction with transition from CPOE to
paper-based prescription.
July 12, 2017
Griffon N, Schuers M, Joulakian M, et al. Physician satisfaction with transition from CPOE to paper-based
prescription. Int J Med Inform. 2017;103:42-48. doi:10.1016/j.ijmedinf.2017.04.007.
https://psnet.ahrq.gov/issue/phys…
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psnet.ahrq.gov/node/45212/psn-pdf
November 23, 2016 - The impact of implementation of family-initiated
escalation of care for the deteriorating patient in hospital:
a systematic review.
November 23, 2016
Gill FJ, Leslie GD, Marshall AP. The Impact of Implementation of Family-Initiated Escalation of Care for the
Deteriorating Patient in Hospital: A Systematic Review. …
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psnet.ahrq.gov/node/45520/psn-pdf
October 05, 2016 - Defining excellence: next steps for practicing clinicians
seeking to prevent diagnostic error.
October 5, 2016
Foster PN, Klein JR. Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic
error. J Community Hosp Intern Med Perspect. 2016;6(4):31994. doi:10.3402/jchimp.v6.31994.
http…
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psnet.ahrq.gov/node/42264/psn-pdf
May 25, 2022 - Safety Considerations for Container Labels and Carton
Labeling Design to Minimize Medication Errors: Guidance
for Industry.
May 25, 2022
Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for
Drug Evaluation and Research; May 18, 2022.
https://psnet.ahrq.gov/issue/safe…
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psnet.ahrq.gov/node/852448/psn-pdf
January 01, 2024 - A realist synthesis of interprofessional patient safety
activities and healthcare student attitudes towards patient
safety.
August 16, 2023
Cleary E, Bloomfield J, Frotjold A, et al. A realist synthesis of interprofessional patient safety activities and
healthcare student attitudes towards patient safety. J Interp…
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psnet.ahrq.gov/node/43931/psn-pdf
March 04, 2015 - Design of endoscopic retrograde
cholangiopancreatography (ERCP) duodenoscopes may
impede effective cleaning.
March 4, 2015
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 23, 2015.
https://psnet.ahrq.gov/issue/design-endoscopic-retrograde-cholangiopancreatography-ercp-
duode…
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psnet.ahrq.gov/node/46760/psn-pdf
January 24, 2018 - Systematic evidence review of rates and burden of harm
of intravenous admixture drug preparation errors in
healthcare settings.
January 24, 2018
Hedlund N, Beer I, Hoppe-Tichy T, et al. Systematic evidence review of rates and burden of harm of
intravenous admixture drug preparation errors in healthcare settings. B…
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psnet.ahrq.gov/node/43625/psn-pdf
October 29, 2014 - Assessing distractors and teamwork during surgery:
developing an event-based method for direct observation.
October 29, 2014
Seelandt JC, Tschan F, Keller S, et al. Assessing distractors and teamwork during surgery: developing an
event-based method for direct observation. BMJ Qual Saf. 2014;23(11):918-29. doi:10.11…
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psnet.ahrq.gov/node/845657/psn-pdf
March 08, 2023 - Dissemination and Implementation of Equity-Focused
Evidence-Based Interventions in Healthcare Delivery
Systems (R18).
March 8, 2023
Rockville, MD: Agency for Healthcare Research and Quality. February 15, 2023. RFA-HS-23-002.
https://psnet.ahrq.gov/issue/dissemination-and-implementation-equity-focused-evidence-base…
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psnet.ahrq.gov/node/851652/psn-pdf
July 26, 2023 - Breast cancer missed at screening; hindsight or
mistakes?
July 26, 2023
Hovda T, Larsen M, Romundstad L, et al. Breast cancer missed at screening; hindsight or mistakes? Eur J
Radiol. 2023;165:110913. doi:10.1016/j.ejrad.2023.110913.
https://psnet.ahrq.gov/issue/breast-cancer-missed-screening-hindsight-or-mistakes…
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psnet.ahrq.gov/node/72606/psn-pdf
December 23, 2020 - Best Practices in Developing Proprietary Names for
Human Prescription Drug Products Guidance for Industry.
December 23, 2020
Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for
Drug Evaluation and Research; December 2020.
https://psnet.ahrq.gov/issue/best-practices-d…
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psnet.ahrq.gov/node/44538/psn-pdf
October 21, 2015 - Timing of the diagnosis of attention-deficit/hyperactivity
disorder and autism spectrum disorder.
October 21, 2015
Miodovnik A, Harstad E, Sideridis G, et al. Timing of the Diagnosis of Attention-Deficit/Hyperactivity
Disorder and Autism Spectrum Disorder. Pediatrics. 2015;136(4):e830-7. doi:10.1542/peds.2015-1502.…