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psnet.ahrq.gov/node/43665/psn-pdf
November 20, 2015 - Patient safety education to change medical students'
attitudes and sense of responsibility.
November 20, 2015
Roh H, Park SJ, Kim T. Patient safety education to change medical students' attitudes and sense of
responsibility. Med Teach. 2015;37(10):908-14. doi:10.3109/0142159X.2014.970988.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/36005/psn-pdf
March 28, 2011 - Active surveillance using electronic triggers to detect
adverse events in hospitalized patients.
March 28, 2011
Szekendi MK, Sullivan C, Bobb A, et al. Active surveillance using electronic triggers to detect adverse
events in hospitalized patients. Qual Saf Health Care. 2006;15(3):184-90.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/46047/psn-pdf
May 17, 2017 - Medicare failed to investigate suspicious infection cases
from 96 hospitals.
May 17, 2017
Jewett C. Kaiser Health News. May 9, 2017.
https://psnet.ahrq.gov/issue/medicare-failed-investigate-suspicious-infection-cases-96-hospitals
The Centers for Medicare and Medicaid Services decision to withhold payment for certa…
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psnet.ahrq.gov/node/60676/psn-pdf
July 15, 2020 - Northeastern University Hospital Surge Capacity Planning
Model: Bed, Ventilator, and PPE 1-30 Day Demand.
July 15, 2020
Rockville, MD; Agency for Healthcare Research and Quality: 2020.
https://psnet.ahrq.gov/issue/northeastern-university-hospital-surge-capacity-planning-model-bed-ventilator-
and-ppe-1-30
The COVI…
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psnet.ahrq.gov/node/866728/psn-pdf
September 18, 2024 - ROI for a fall prevention intervention: invest a little, save a
lot.
September 18, 2024
Cooper AS. ROI for a fall prevention intervention: invest a little, save a lot. Nurs Adm Q. 2024;48(3):248-
252. doi:10.1097/naq.0000000000000647.
https://psnet.ahrq.gov/issue/roi-fall-prevention-intervention-invest-little-save…
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psnet.ahrq.gov/node/866439/psn-pdf
August 07, 2024 - Associations between negative patient safety climate and
infection prevention practices.
August 7, 2024
Johnson CT, Hessels AJ. Associations between negative patient safety climate and infection prevention
practices. Am J Infect Control. 2024;52(9):1102-1104. doi:10.1016/j.ajic.2024.06.010.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/42362/psn-pdf
July 10, 2013 - How to improve change of shift handovers and
collaborative grounding and what role does the electronic
patient record system play? Results of a systematic
literature review.
July 10, 2013
Flemming D, Hübner U. How to improve change of shift handovers and collaborative grounding and what
role does the electronic p…
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psnet.ahrq.gov/node/44926/psn-pdf
January 23, 2017 - How might health services capture patient-reported safety
concerns in a hospital setting? An exploratory pilot study
of three mechanisms.
January 23, 2017
O'Hara JK, Armitage G, Reynolds C, et al. How might health services capture patient-reported safety
concerns in a hospital setting? An exploratory pilot study o…
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psnet.ahrq.gov/node/44195/psn-pdf
June 06, 2018 - An assessment of basic patient safety skills in residents
entering the first year of clinical training.
June 6, 2018
Comunale ME, Sandoval M, Broussard LT. An Assessment of Basic Patient Safety Skills in Residents
Entering the First Year of Clinical Training. J Patient Saf. 2018;14(2):112-114.
doi:10.1097/PTS.0000…
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psnet.ahrq.gov/node/47924/psn-pdf
June 05, 2019 - Effect of a central call center on employee perceptions of
safety culture within community pharmacies in an
academic health system.
June 5, 2019
Bowden A, Mullin S, Tak C, et al. Effect of a central call center on employee perceptions of safety culture
within community pharmacies in an academic health system. Am J…
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psnet.ahrq.gov/node/45935/psn-pdf
September 29, 2017 - Radiology research in quality and safety: current trends
and future needs.
September 29, 2017
Zygmont ME, Itri JN, Rosenkrantz AB, et al. Radiology Research in Quality and Safety: Current Trends and
Future Needs. Acad Radiol. 2017;24(3):263-272. doi:10.1016/j.acra.2016.07.021.
https://psnet.ahrq.gov/issue/radiolog…
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psnet.ahrq.gov/node/74269/psn-pdf
January 19, 2022 - Safety culture, safety climate, and safety performance in
healthcare facilities: a systematic review.
January 19, 2022
Noor Arzahan IS, Ismail Z, Yasin SM. Safety culture, safety climate, and safety performance in healthcare
facilities: A systematic review. Safety Sci. 2022;147:105624. doi:10.1016/j.ssci.2021.10562…
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psnet.ahrq.gov/node/839812/psn-pdf
November 09, 2022 - Measuring psychological safety and local learning to
enable high reliability organisational change.
November 9, 2022
Cartland J, Green M, Kamm D, et al. Measuring psychological safety and local learning to enable high
reliability organisational change. BMJ Open Qual. 2022;11(4):e001757. doi:10.1136/bmjoq-2021-00175…
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psnet.ahrq.gov/node/46141/psn-pdf
May 17, 2017 - Ethical dilemma in missed melanoma: what to tell the
patient and other providers.
May 17, 2017
Vangipuram R, Horner ME, Menter A. Ethical dilemma in missed melanoma: What to tell the patient and
other providers. J Am Acad Dermatol. 2017;76(2):365-367. doi:10.1016/j.jaad.2016.08.030.
https://psnet.ahrq.gov/issue/et…
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psnet.ahrq.gov/node/47438/psn-pdf
June 02, 2019 - Developing an intervention to reduce harm in hospitalized
patients: patients and families in research.
June 2, 2019
Schenk EC, Bryant RA, Van Son CR, et al. Developing an Intervention to Reduce Harm in Hospitalized
Patients: Patients and Families in Research. J Nurs Care Qual. 2019;34(3):273-278.
doi:10.1097/NCQ.0…
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psnet.ahrq.gov/node/837670/psn-pdf
July 13, 2022 - The evidence base for US Joint Commission hospital
accreditation standards: cross sectional study.
July 13, 2022
Ibrahim SA, Reynolds KA, Poon E, et al. The evidence base for US joint commission hospital accreditation
standards: cross sectional study. BMJ. 2022;377:e063064. doi:10.1136/bmj-2020-063064.
https://psn…
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psnet.ahrq.gov/node/60152/psn-pdf
March 25, 2020 - Errors during resuscitation: the impact of perceived
authority on delivery of care.
March 25, 2020
Delaloye NJ, Tobler K, O?Neill T, et al. Errors during resuscitation: the impact of perceived authority on
delivery of care. J Patient Saf. 2020;16(1). doi:10.1097/pts.0000000000000359.
https://psnet.ahrq.gov/issue/e…
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psnet.ahrq.gov/node/841759/psn-pdf
December 21, 2022 - Sources of nurse-sensitive inpatient safety improvement.
December 21, 2022
Dynan L, Smith RB. Sources of nurse?sensitive inpatient safety improvement. Health Serv Res.
2022;57(6):1235-1246. doi:10.1111/1475-6773.13979.
https://psnet.ahrq.gov/issue/sources-nurse-sensitive-inpatient-safety-improvement
Nurses play a …
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psnet.ahrq.gov/node/34700/psn-pdf
January 04, 2017 - Reducing adverse drug events: lessons from a
breakthrough series collaborative.
January 4, 2017
Leape L, Kabcenell AI, Gandhi TK, et al. Reducing adverse drug events: lessons from a breakthrough
series collaborative. Jt Comm J Qual Improv. 2000;26(6):321-31.
https://psnet.ahrq.gov/issue/reducing-adverse-drug-event…
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psnet.ahrq.gov/node/49822/psn-pdf
March 01, 2018 - Isolated Clot, Real Error
March 1, 2018
Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/isolated-clot-real-error
Case Objectives
Appreciate that errors are common in the management of venous thromboembolism disease.
Describe patients with venous thromboembolism i…