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psnet.ahrq.gov/node/44903/psn-pdf
September 27, 2016 - What would you ideally do if there were no targets? An
ethnographic study of the unintended consequences of
top-down governance in two clinical settings.
September 27, 2016
Allard J, Bleakley A. What would you ideally do if there were no targets? An ethnographic study of the
unintended consequences of top-down gov…
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psnet.ahrq.gov/node/45371/psn-pdf
April 24, 2017 - Patient safety and workplace bullying: an integrative
review.
April 24, 2017
Houck NM, Colbert AM. Patient Safety and Workplace Bullying: An Integrative Review. J Nurs Care Qual.
2017;32(2):164-171. doi:10.1097/NCQ.0000000000000209.
https://psnet.ahrq.gov/issue/patient-safety-and-workplace-bullying-integrative-rev…
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psnet.ahrq.gov/node/47304/psn-pdf
October 24, 2018 - Mind the overlap: how system problems contribute to
cognitive failure and diagnostic errors.
October 24, 2018
Gupta A, Harrod M, Quinn M, et al. Mind the overlap: how system problems contribute to cognitive failure
and diagnostic errors. Diagnosis (Berl). 2018;5(3):151-156. doi:10.1515/dx-2018-0014.
https://psnet.…
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psnet.ahrq.gov/node/48013/psn-pdf
May 29, 2019 - Economic outcomes associated with safety interventions
by a pharmacist–adjudicated prior authorization consult
service.
May 29, 2019
Jacob S, Britt RB, Bryan WE, et al. Economic Outcomes Associated with Safety Interventions by a
Pharmacist-Adjudicated Prior Authorization Consult Service. J Manag Care Spec Pharm. 2…
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psnet.ahrq.gov/node/47866/psn-pdf
May 11, 2019 - Effect of a cluster randomised team training intervention
on adverse perinatal and maternal outcomes: a stepped
wedge study.
May 11, 2019
Romijn A, Ravelli A, de Bruijne MC, et al. Effect of a cluster randomised team training intervention on
adverse perinatal and maternal outcomes: a stepped wedge study. BJOG. 201…
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psnet.ahrq.gov/node/43794/psn-pdf
January 14, 2015 - Prescriber barriers and enablers to minimising potentially
inappropriate medications in adults: a systematic review
and thematic synthesis.
January 14, 2015
Anderson K, Stowasser D, Freeman C, et al. Prescriber barriers and enablers to minimising potentially
inappropriate medications in adults: a systematic review…
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psnet.ahrq.gov/node/48010/psn-pdf
May 22, 2019 - In-situ interprofessional perinatal drills: the impact of a
structured debrief on maximizing training while sensing
patient safety threats.
May 22, 2019
Greer JA, Haischer-Rollo G, Delorey D, et al. In-situ Interprofessional Perinatal Drills: The Impact of a
Structured Debrief on Maximizing Training While Sensing …
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psnet.ahrq.gov/node/36199/psn-pdf
March 28, 2011 - Time of day effects on the incidence of anesthetic
adverse events.
March 28, 2011
Wright MC, Phillips-Bute B, Mark JB, et al. Time of day effects on the incidence of anesthetic adverse
events. Qual Saf Health Care. 2006;15(4):258-63.
https://psnet.ahrq.gov/issue/time-day-effects-incidence-anesthetic-adverse-events…
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psnet.ahrq.gov/node/34807/psn-pdf
January 01, 2019 - The Quality in Australian Health Care Study.
November 18, 2015
Wilson RML, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust.
2019;163(9):458-471. doi:10.5694/j.1326-5377.1995.tb124691.x.
https://psnet.ahrq.gov/issue/quality-australian-health-care-study
In order to estimate pa…
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psnet.ahrq.gov/node/47012/psn-pdf
August 01, 2018 - Trigger alerts associated with laboratory abnormalities on
identifying potentially preventable adverse drug events in
the intensive care unit and general ward.
August 1, 2018
Buckley MS, Rasmussen JR, Bikin DS, et al. Trigger alerts associated with laboratory abnormalities on
identifying potentially preventable ad…
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psnet.ahrq.gov/node/34803/psn-pdf
January 05, 2017 - Systematic root cause analysis of adverse drug events in
a tertiary referral hospital.
January 5, 2017
Rex JH, Turnbull JE, Allen SJ, et al. Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary
Referral Hospital. Jt Comm J Qual Improv. 2016;26(10). doi:10.1016/s1070-3241(00)26048-3.
https://psnet.ah…
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psnet.ahrq.gov/node/46474/psn-pdf
November 08, 2017 - Clearing the Error: Using Public Deliberation to Define
Patient Roles as Partners in the Diagnostic Process.
November 8, 2017
St. Paul, MN: Society to Improve Diagnosis in Medicine, Maxwell School of Citizenship and Public Affairs at
Syracuse University, and Jefferson Center; 2017.
https://psnet.ahrq.gov/issue/cle…
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psnet.ahrq.gov/node/41561/psn-pdf
August 01, 2012 - Few Adverse Events in Hospitals Were Reported to State
Adverse Event Reporting Systems.
August 1, 2012
Wright S. Washington, DC: US Department of Health and Human Services, Office of the Inspector General;
July 2012. Report No. OEI-06-09-00092.
https://psnet.ahrq.gov/issue/few-adverse-events-hospitals-were-reporte…
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psnet.ahrq.gov/node/844759/psn-pdf
September 18, 2019 - Saving Patient Ryan- can advanced electronic medical
records make patient care safer?
September 18, 2019
Hydari MZ, Telang R, Marella WM. Manage Sci. 2019;65:2041-2059.
https://psnet.ahrq.gov/issue/saving-patient-ryan-can-advanced-electronic-medical-records-make-patient-
care-safer
This observational study examin…
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psnet.ahrq.gov/node/840488/psn-pdf
November 30, 2022 - Critical care clinicians' experiences of patient safety
during the COVID-19 pandemic.
November 30, 2022
Rosen A, Carter D, Applebaum JR, et al. Critical care clinicians' experiences of patient safety during the
COVID-19 pandemic. J Patient Saf. 2022;18(8):e1219-e1225. doi:10.1097/pts.0000000000001060.
https://psne…
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psnet.ahrq.gov/node/866283/psn-pdf
July 10, 2024 - Safety and Quality of Parenteral Nutrition: Translating
Guidelines into Clinical Practice Considering Different
Organizational Settings.
July 10, 2024
Am J Health Syst Pharm. 2024;81(supp 3):s73-s136.
https://psnet.ahrq.gov/issue/safety-and-quality-parenteral-nutrition-translating-guidelines-clinical-practice-
co…
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psnet.ahrq.gov/node/837983/psn-pdf
August 31, 2022 - Identifying and Understanding Ways to Address the
Impact of Racism on Patient Safety in Health Care
Settings.
August 31, 2022
Schulson LB, Thomas AD, Tsuei J, et al. Santa Monica, CA: RAND Corporation; 2022
https://psnet.ahrq.gov/issue/identifying-and-understanding-ways-address-impact-racism-patient-safety-
…
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psnet.ahrq.gov/node/44406/psn-pdf
December 04, 2016 - Drug manufacturers' delayed disclosure of serious and
unexpected adverse events to the US Food and Drug
Administration.
December 4, 2016
Ma P, Marinovic I, Karaca-Mandic P. Drug Manufacturers' Delayed Disclosure of Serious and Unexpected
Adverse Events to the US Food and Drug Administration. JAMA Intern Med. 2015;…
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psnet.ahrq.gov/node/44490/psn-pdf
September 16, 2015 - Implementation of a custom alert to prevent medication-
timing errors associated with computerized prescriber
order entry.
September 16, 2015
Idemoto LM, Williams BL, Ching JM, et al. Implementation of a custom alert to prevent medication-timing
errors associated with computerized prescriber order entry. Am J Heal…
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psnet.ahrq.gov/node/854830/psn-pdf
January 01, 2024 - The effect of evidence in crisis learning: based on a
perspective integration framework.
October 25, 2023
Wang B, Li D, Wang Y. The effect of evidence in crisis learning: based on a perspective integration
framework. J Contingencies Crisis Manag. 2024;32(1):e12506. doi:10.1111/1468-5973.12506.
https://psnet.ahrq.g…