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psnet.ahrq.gov/node/42173/psn-pdf
April 24, 2013 - Hand hygiene and healthcare system change within multi-
modal promotion: a narrative review.
April 24, 2013
Allegranzi B, Sax H, Pittet D. Hand hygiene and healthcare system change within multi-modal promotion: a
narrative review. J Hosp Infect. 2013;83 Suppl 1:S3-10. doi:10.1016/S0195-6701(13)60003-1.
https://psn…
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psnet.ahrq.gov/node/46800/psn-pdf
May 16, 2018 - Ireland investigates cervical cancer screening scandal.
May 16, 2018
O'Loughlin E. New York Times. April 30, 2018.
https://psnet.ahrq.gov/issue/ireland-investigates-cervical-cancer-screening-scandal
Large-scale adverse events should lead to system examination and improvement. This newspaper article
reports on misr…
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psnet.ahrq.gov/node/74045/psn-pdf
November 03, 2021 - ‘They treat me like I’m old and stupid’: seniors decry
health providers’ age bias.
November 3, 2021
Graham J. Kaiser Health News. October 20, 2021.
https://psnet.ahrq.gov/issue/they-treat-me-im-old-and-stupid-seniors-decry-health-providers-age-bias
Implicit biases permeate decision making and can impede safe and e…
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psnet.ahrq.gov/node/843322/psn-pdf
February 01, 2023 - A deadly epidural, delivered by a doctor with a history of
mistakes.
February 1, 2023
Goldstein J. New York Times. January 23, 2023.
https://psnet.ahrq.gov/issue/deadly-epidural-delivered-doctor-history-mistakes
Active errors are evident when they occur, yet systemic weaknesses, if not addressed, allow them to rep…
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psnet.ahrq.gov/node/838258/psn-pdf
October 05, 2022 - Solutions from Professional Regulation and Beyond.
October 5, 2022
Safer Care for All. London, England: Professional Standards Authority for Health and Social Care;
2022.
https://psnet.ahrq.gov/issue/solutions-professional-regulation-and-beyond
Dedicated leadership is an important component to examine and ad…
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psnet.ahrq.gov/node/867019/psn-pdf
October 23, 2024 - Reports on Hospital and ASC Performance.
October 23, 2024
Reports On Hospital And Asc Performance. Washington DC: The Leapfrog Group; September 2024.
https://psnet.ahrq.gov/issue/reports-hospital-and-asc-performance
Data collection and transparency are known to motivate change and drive improvement efforts. This se…
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psnet.ahrq.gov/node/35181/psn-pdf
June 23, 2009 - Communication during trauma resuscitation: do we know
what is happening?
June 23, 2009
Bergs EAG, Rutten FLPA, Tadros T, et al. Communication during trauma resuscitation: do we know what is
happening? Injury. 2005;36(8):905-11.
https://psnet.ahrq.gov/issue/communication-during-trauma-resuscitation-do-we-know-what-…
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psnet.ahrq.gov/node/844778/psn-pdf
September 18, 2019 - Assessing clinical reasoning: targeting the higher levels
of the pyramid.
September 18, 2019
Thampy H, Willert E, Ramani S. Assessing Clinical Reasoning: Targeting the Higher Levels of the Pyramid.
J Gen Intern Med. 2019;34(8):1631-1636. doi:10.1007/s11606-019-04953-4.
https://psnet.ahrq.gov/issue/assessing-clinic…
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psnet.ahrq.gov/node/839328/psn-pdf
November 02, 2022 - Quality and Safety.
November 2, 2022
Iyer R, Walker A, eds. Paediatr Anaesth. 2022;32(11):1176-1272.
https://psnet.ahrq.gov/issue/quality-and-safety-1
Progress made in the adoption of infrastructure, Safety I, and Safety II concepts in high- and middle- to
lower-income countries around the world support safe pedia…
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psnet.ahrq.gov/node/73327/psn-pdf
January 25, 2022 - ISMP Medication Safety Self Assessment® for
Perioperative Settings.
January 25, 2022
Institute for Safe Medication Practices
https://psnet.ahrq.gov/issue/ismp-medication-safety-self-assessmentr-perioperative-settings
The perioperative setting is a high-risk area for medication errors, should they occur. This asses…
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psnet.ahrq.gov/node/41722/psn-pdf
October 17, 2012 - Remaking surgical socialization: work hour restrictions,
rites of passage, and occupational identity.
October 17, 2012
Veazey Brooks J, Bosk CL. Remaking surgical socialization: Work hour restrictions, rites of passage, and
occupational identity. Soc Sci Med. 2012;75(9). doi:10.1016/j.socscimed.2012.07.007.
https:…
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psnet.ahrq.gov/node/50826/psn-pdf
January 22, 2020 - Health Informatics, Healthcare Quality and Safety, and
Healthcare Simulation: the New Triad to Advance
Healthcare Operations
January 22, 2020
Feldman SS, Brazil V, Zengul FD, et al, eds. Health Syst (Basingstoke). 2019;8(3):153-227.
https://psnet.ahrq.gov/issue/health-informatics-healthcare-quality-and-safety-and-…
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psnet.ahrq.gov/node/50623/psn-pdf
November 06, 2019 - Adverse Events in Anesthesia: An Integrative Review.
November 6, 2019
Lemos C de S, Poveda V de B. Adverse Events in Anesthesia: An Integrative Review. J Perianesth Nurs.
2019;34(5):978-998. doi:10.1016/j.jopan.2019.02.005.
https://psnet.ahrq.gov/issue/adverse-events-anesthesia-integrative-review
This integrative …
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psnet.ahrq.gov/node/863766/psn-pdf
March 06, 2024 - Legacy: a Black Physician Reckons with Racism in
Medicine.
March 6, 2024
Blackstock U. New York, NY: Viking; 2024. ISBN: 9780593491287.
https://psnet.ahrq.gov/issue/legacy-black-physician-reckons-racism-medicine
The history of systemic racism is emerging to motivate health care equity and safety efforts. This memo…
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psnet.ahrq.gov/node/37760/psn-pdf
May 14, 2008 - The role of continuous quality improvement and
psychological safety in predicting work-arounds.
May 14, 2008
Halbesleben JRB, Rathert C. The role of continuous quality improvement and psychological safety in
predicting work-arounds. Health Care Manage Rev. 2008;33(2):134-44.
doi:10.1097/01.HMR.0000304505.04932.62.…
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psnet.ahrq.gov/node/74708/psn-pdf
January 26, 2022 - COVID Risk In Hospitals.
January 26, 2022
Weber L, Jewett C. Kaiser Health News. 2021-2022.
https://psnet.ahrq.gov/issue/covid-risk-hospitals
The infectious nature of COVID continues to impact the safety of hospitalized patients. This article series
examines factors contributing to hospital-acquired COVID-19 infec…
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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/42687/psn-pdf
September 29, 2017 - Safety checklist compliance and a false sense of safety:
new directions for research.
September 29, 2017
Rydenfält C, Ek Å, Larsson PA. Safety checklist compliance and a false sense of safety: new directions for
research. BMJ Qual Saf. 2014;23(3):183-6. doi:10.1136/bmjqs-2013-002168.
https://psnet.ahrq.gov/issue/s…
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psnet.ahrq.gov/issue/pathology-and-patient-safety-critical-role-pathology-informatics-error-reduction-and-quality
July 20, 2009 - Resources From the Same Author(s)
Database construction for improving patient safety by examining
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psnet.ahrq.gov/issue/does-your-knee-make-more-click-or-clack-teaching-car-talk-new-docs
April 17, 2019 - November 4, 2014
Examining the diagnostic justification abilities of fourth-year medical