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psnet.ahrq.gov/node/37849/psn-pdf
March 23, 2011 - The incidence and nature of in-hospital adverse events: a
systematic review.
March 23, 2011
de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse
events: a systematic review. Qual Saf Health Care. 2008;17(3):216-223. doi:10.1136/qshc.2007.023622.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/37091/psn-pdf
March 02, 2016 - The tension between needing to improve care and
knowing how to do it.
March 2, 2016
Auerbach AD, Landefeld S, Shojania KG. The tension between needing to improve care and knowing how
to do it. N Engl J Med. 2007;357(6):608-13.
https://psnet.ahrq.gov/issue/tension-between-needing-improve-care-and-knowing-how-do-it
…
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psnet.ahrq.gov/node/40921/psn-pdf
November 16, 2011 - Adverse Events in Hospitals: Medicare's Responses to
Alleged Serious Events.
November 16, 2011
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector
General; October 2011. Report No. OEI-01-08-00590.
https://psnet.ahrq.gov/issue/adverse-events-hospitals-medicares-response…
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psnet.ahrq.gov/node/36455/psn-pdf
December 22, 2010 - Changing the work environment in ICUs to achieve
patient-focused care: the time has come.
December 22, 2010
McCauley K, Irwin RS. Changing the work environment in ICUs to achieve patient-focused care: the time
has come. Chest. 2006;130(5):1571-8.
https://psnet.ahrq.gov/issue/changing-work-environment-icus-achieve-…
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psnet.ahrq.gov/node/60017/psn-pdf
March 04, 2020 - Changes in cancer detection and false-positive recall in
mammography using artificial intelligence: a
retrospective, multireader study.
March 4, 2020
Kim H-E, Kim HH, Han B-K, et al. Changes in cancer detection and false-positive recall in mammography
using artificial intelligence: a retrospective, multireader stu…
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psnet.ahrq.gov/node/839816/psn-pdf
January 01, 2023 - Gender bias in risk management reports involving
physicians in training - a retrospective qualitative study.
November 9, 2022
Andraska EA, Phillips AR, Asaadi S, et al. Gender bias in risk management reports involving physicians in
training - a retrospective qualitative study. J Surg Educ. 2023;80(1):102-109.
doi:…
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psnet.ahrq.gov/node/866312/psn-pdf
July 17, 2024 - Development of patient safety measures to identify
inappropriate diagnosis of common infections.
July 17, 2024
White AT, Vaughn VM, Petty LA, et al. Development of patient safety measures to identify inappropriate
diagnosis of common infections. Clin Infect Dis. 2024;78(6):1403-1411. doi:10.1093/cid/ciae044.
https…
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psnet.ahrq.gov/node/866517/psn-pdf
August 14, 2024 - Feedback loop failure modes in medical diagnosis: how
biases can emerge and be reinforced.
August 14, 2024
Aikens RC, Chen JH, Baiocchi M, et al. Feedback loop failure modes in medical diagnosis: how biases can
emerge and be reinforced. Med Decis Making. 2024;44(5):481-496. doi:10.1177/0272989x241248612.
https://p…
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psnet.ahrq.gov/node/50573/psn-pdf
October 23, 2019 - Preventing patient harm via adverse event review: An
APSA survey regarding the role of morbidity and mortality
(M&M) conference.
October 23, 2019
Berman L, Ottosen M, Renaud E, et al. Preventing patient harm via adverse event review: An APSA survey
regarding the role of morbidity and mortality (M&M) conference. J …
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psnet.ahrq.gov/node/848318/psn-pdf
May 03, 2023 - Teamwork, clinical leadership skills and environmental
factors that influence missed nursing care - a qualitative
study on hospital wards.
May 3, 2023
Beiboer C, Andela R, Hafsteinsdóttir TB, et al. Teamwork, clinical leadership skills and environmental
factors that influence missed nursing care – a qualitative st…
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psnet.ahrq.gov/node/38935/psn-pdf
March 01, 2017 - Leadership committed to safety.
December 23, 2016
Sentinel Event Alert. August 27, 2009;(43):1-3.
https://psnet.ahrq.gov/issue/leadership-committed-safety
Despite the past decade's focus on improving patient safety, most health care organizations are still striving
to achieve high reliability status—consistently p…
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psnet.ahrq.gov/node/837799/psn-pdf
August 10, 2022 - Effect of a pharmacy-based centralized intravenous
admixture service on the prevalence of medication errors:
a before-and-after study.
August 10, 2022
Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. Effect of a pharmacy-based centralized intravenous
admixture service on the prevalence of medication errors: a befo…
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psnet.ahrq.gov/node/837069/psn-pdf
January 01, 2024 - Usability of a human factors-based clinical decision
support in the emergency department: lessons learned
for design and implementation.
May 11, 2022
Salwei ME, Hoonakker PLT, Carayon P, et al. Usability of a human factors-based clinical decision support
in the emergency department: lessons learned for design and …
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psnet.ahrq.gov/node/33901/psn-pdf
August 01, 2023 - Patient Safety Indicators Overview.
August 1, 2023
Agency for Healthcare Research and Quality
https://psnet.ahrq.gov/issue/patient-safety-indicators-overview
The AHRQ Patient Safety Indicators (PSIs) represent quality measures that make use of a hospital's
available administrative data. The PSIs reflect the qualit…
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psnet.ahrq.gov/node/73132/psn-pdf
April 14, 2021 - Association of clinician diagnostic performance with
machine learning–based decision support systems: a
systematic review.
April 14, 2021
Vasey B, Ursprung S, Beddoe B, et al. Association of clinician diagnostic performance with machine
learning–based decision support systems: a systematic review. JAMA Netw Open. …
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psnet.ahrq.gov/node/39358/psn-pdf
October 13, 2010 - Hospital safety climate and safety outcomes: is there a
relationship in the VA?
October 13, 2010
Rosen AK, Singer SJ, Zhao S, et al. Hospital safety climate and safety outcomes: is there a relationship in
the VA? Med Care Res Rev. 2010;67(5):590-608. doi:10.1177/1077558709356703.
https://psnet.ahrq.gov/issue/hospi…
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psnet.ahrq.gov/node/46309/psn-pdf
December 22, 2018 - Effects of the I-PASS nursing handoff bundle on
communication quality and workflow.
December 22, 2018
Starmer AJ, Schnock KO, Lyons A, et al. Effects of the I-PASS Nursing Handoff Bundle on communication
quality and workflow. BMJ Qual Saf. 2017;26(12):949-957. doi:10.1136/bmjqs-2016-006224.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/36518/psn-pdf
March 28, 2011 - Nurses' attitudes to a medical emergency team service in
a teaching hospital.
March 28, 2011
Jones D, Baldwin I, McIntyre T, et al. Nurses' attitudes to a medical emergency team service in a teaching
hospital. Qual Saf Health Care. 2006;15(6):427-32.
https://psnet.ahrq.gov/issue/nurses-attitudes-medical-emergency-…
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psnet.ahrq.gov/node/866687/psn-pdf
September 11, 2024 - An exploratory analysis of the association between
healthcare associated infections & hospital financial
performance.
September 11, 2024
Beauvais B, Dolezel D, Shanmugam R, et al. An exploratory analysis of the association between
healthcare associated infections & hospital financial performance. Healthcare (Basel…
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psnet.ahrq.gov/node/41494/psn-pdf
June 27, 2012 - National Voluntary Consensus Standards for Patient
Safety Measures: A Consensus Report.
June 27, 2012
Washington, DC: National Quality Forum; June 2012.
https://psnet.ahrq.gov/issue/national-voluntary-consensus-standards-patient-safety-measures-consensus-
report
Progress in improving patient safety has been hampe…