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psnet.ahrq.gov/node/74006/psn-pdf
October 27, 2021 - Building patient trust in hospitals: a combination of
hospital-related factors and health care clinician
behaviors.
October 27, 2021
Greene J, Samuel-Jakubos H. Building patient trust in hospitals: a combination of hospital-related factors
and health care clinician behaviors. Jt Comm J Qual Patient Saf. 2021;47(12…
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psnet.ahrq.gov/node/43777/psn-pdf
January 01, 2015 - Smartphones let surgeons know WhatsApp: an analysis
of communication in emergency surgical teams.
December 17, 2014
Johnston MJ, King D, Arora S, et al. Smartphones let surgeons know WhatsApp: an analysis of
communication in emergency surgical teams. Am J Surg. 2015;209(1):45-51.
doi:10.1016/j.amjsurg.2014.08.030.…
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psnet.ahrq.gov/node/38060/psn-pdf
April 11, 2011 - Iatrogenesis in neonatal intensive care units:
observational and interventional, prospective, multicenter
study.
April 11, 2011
Kugelman A, Inbar-Sanado E, Shinwell ES, et al. Iatrogenesis in neonatal intensive care units:
observational and interventional, prospective, multicenter study. Pediatrics. 2008;122(3):55…
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psnet.ahrq.gov/node/44285/psn-pdf
November 06, 2015 - Hospital board oversight of quality and safety: a
stakeholder analysis exploring the role of trust and
intelligence.
November 6, 2015
Millar R, Freeman T, Mannion R. Hospital board oversight of quality and safety: a stakeholder analysis
exploring the role of trust and intelligence. BMC Health Serv Res. 2015;15:196…
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psnet.ahrq.gov/node/72607/psn-pdf
December 23, 2020 - Defense Health Agency Processes for Responding to
Provider Quality and Safety Concerns.
December 23, 2020
Washington DC; Governmental Accountability Office; December 1, 2020. Publication GAO-21-160R.
https://psnet.ahrq.gov/issue/defense-health-agency-processes-responding-provider-quality-and-safety-
concerns
Clin…
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psnet.ahrq.gov/node/854387/psn-pdf
October 11, 2023 - Healthcare resilience: a meta-narrative systematic review
and synthesis of reviews.
October 11, 2023
Tan MZY, Prager G, McClelland A, et al. Healthcare resilience: a meta-narrative systematic review and
synthesis of reviews. BMJ Open. 2023;13(9):e072136. doi:10.1136/bmjopen-2023-072136.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/863002/psn-pdf
February 21, 2024 - Three quarters of preventable patient harm stems from
situation awareness breakdowns: recognizing and
addressing the core issue.
February 21, 2024
Tscholl DW, Hunn CA, Gasciauskaite G. APSF Newsletter. 2024;39:29–30.
https://psnet.ahrq.gov/issue/three-quarters-preventable-patient-harm-stems-situation-awareness-
b…
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psnet.ahrq.gov/node/48075/psn-pdf
June 19, 2019 - A mismatch made in America.
June 19, 2019
Butcher L. Managed Care. June 2019;28:37-39.
https://psnet.ahrq.gov/issue/mismatch-made-america
Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient
errors. This magazine article reports on the complex nature of addressing …
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psnet.ahrq.gov/node/74042/psn-pdf
November 03, 2021 - An Investigation into the Death of Baby J at University
Hospitals Bristol and Weston NHS Foundation Trust.
November 3, 2021
Manchester, UK: Parliamentary and Health Service Ombudsman; October 2021.
https://psnet.ahrq.gov/issue/investigation-death-baby-j-university-hospitals-bristol-and-weston-nhs-
foundation-trust…
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psnet.ahrq.gov/node/840163/psn-pdf
November 16, 2022 - Deep Dive: Racial and Ethnic Disparities in Health and
Healthcare.
November 16, 2022
Plymouth Meeting, PA: ECRI and the Institute for Safe Medication Practices; 2022.
https://psnet.ahrq.gov/issue/deep-dive-racial-and-ethnic-disparities-health-and-healthcare
Racist behavior directed at either patients or clinicians…
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psnet.ahrq.gov/node/37909/psn-pdf
February 23, 2009 - Prevalence of adverse drug combinations in a large post-
mortem toxicology database.
February 23, 2009
Launiainen T, Vuori E, Ojanperä I. Prevalence of adverse drug combinations in a large post-mortem
toxicology database. Int J Legal Med. 2009;123(2):109-15. doi:10.1007/s00414-008-0261-3.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/47801/psn-pdf
May 11, 2019 - Opioid prescribing trends and the physician’s role in
responding to the public health crisis.
May 11, 2019
Adams JM, Giroir BP. Opioid Prescribing Trends and the Physician's Role in Responding to the Public
Health Crisis. JAMA Intern Med. 2019;179(4):476-478. doi:10.1001/jamainternmed.2018.7934.
https://psnet.ahrq…
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psnet.ahrq.gov/node/45264/psn-pdf
September 01, 2016 - Perceived factors associated with sustained improvement
following participation in a multicenter quality
improvement collaborative.
September 1, 2016
Stone S, Lee HC, Sharek PJ. Perceived Factors Associated with Sustained Improvement Following
Participation in a Multicenter Quality Improvement Collaborative. Jt Co…
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psnet.ahrq.gov/node/837214/psn-pdf
May 25, 2022 - Global Report on Infection Prevention and Control:
Executive Summary.
May 25, 2022
Geneva, Switzerland; World Health Organization; May 5, 2022.
https://psnet.ahrq.gov/issue/global-report-infection-prevention-and-control-executive-summary
Healthcare-acquired infection is a persistent systemic problem. This report r…
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psnet.ahrq.gov/node/35069/psn-pdf
June 22, 2009 - Towards an organization with a memory: exploring the
organizational generation of adverse events in health
care.
June 22, 2009
Smith D, Toft B. Towards an organization with a memory: exploring the organizational generation of
adverse events in health care. Health Serv Manage Res. 2005;18(2). doi:10.1258/0951484053…
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psnet.ahrq.gov/node/43184/psn-pdf
May 14, 2014 - Often overlooked problems with handoffs: from the
intensive care unit to the operating room.
May 14, 2014
Evans AS, Yee M-S, Hogue CW. Often overlooked problems with handoffs: from the intensive care unit to
the operating room. Anesth Analg. 2014;118(3):687-9. doi:10.1213/ANE.0000000000000075.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/74015/psn-pdf
October 27, 2021 - Safer Services: A Toolkit for Specialist Mental Health
Services and Primary Care.
October 27, 2021
National Confidential Inquiry into Suicide and Safety in Mental Health. Manchester, UK: University of
Manchester; May 31, 2021
https://psnet.ahrq.gov/issue/safer-services-toolkit-specialist-mental-health-services-and…
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psnet.ahrq.gov/node/34797/psn-pdf
October 06, 2015 - Adapting to new technologies in the operating room.
October 6, 2015
Cook RI, Woods DD. Adapting to New Technology in the Operating Room. Hum Factors. 2006;38(4):593-
613. doi:10.1518/001872096778827224.
https://psnet.ahrq.gov/issue/adapting-new-technologies-operating-room
New technology continues to offer great ad…
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psnet.ahrq.gov/node/73429/psn-pdf
June 23, 2021 - Wrong Site Surgery - Wrong Patient: Invasive Procedures
in Outpatient Settings.
June 23, 2021
Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.
https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings
Wrong site/wrong patent surgery is a persisten…
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psnet.ahrq.gov/node/43478/psn-pdf
August 27, 2014 - Is it time to move beyond errors in clinical reasoning and
discuss accuracy?
August 27, 2014
Wood TJ. Is it time to move beyond errors in clinical reasoning and discuss accuracy? Adv Health Sci Educ
Theory Pract. 2014;19(3):403-407. doi:10.1007/s10459-014-9498-4.
https://psnet.ahrq.gov/issue/it-time-move-beyond-er…