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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47193/psn-pdf
    September 05, 2018 - Situation, background, assessment, recommendation (SBAR) communication tool for handoff in health care- a narrative review. September 5, 2018 Shahid S, Thomas S. Situation, background, assessment, recommendation (SBAR) communication tool for handoff in health care; a narrative review. Saf Health. 2018;4(7). doi:10…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38026/psn-pdf
    March 21, 2017 - Does error and adverse event reporting by physicians and nurses differ? March 21, 2017 Rowin EJ, Lucier D, Pauker SG, et al. Does error and adverse event reporting by physicians and nurses differ? Jt Comm J Qual Patient Saf. 2008;34(9):537-545. https://psnet.ahrq.gov/issue/does-error-and-adverse-event-reporting-ph…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848036/psn-pdf
    April 26, 2023 - Using a learning system approach to improve safety for prone-position ventilation patients. April 26, 2023 Thomas AL, Graham KL, Davila S, et al. Using a learning system approach to improve safety for prone- position ventilation patients. J Patient Saf. 2023;19(3):180-184. doi:10.1097/pts.0000000000001108. https:/…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47590/psn-pdf
    February 20, 2019 - Explaining organisational responses to a board-level quality improvement intervention: findings from an evaluation in six providers in the English National Health Service. February 20, 2019 Jones L, Pomeroy L, Robert G, et al. Explaining organisational responses to a board-level quality improvement intervention: …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867591/psn-pdf
    January 22, 2025 - Biased language in simulated handoffs and clinician recall and attitudes. January 22, 2025 Wesevich A, Langan E, Fridman I, et al. Biased language in simulated handoffs and clinician recall and attitudes. JAMA Netw Open. 2024;7(12):e2450172. doi:10.1001/jamanetworkopen.2024.50172. https://psnet.ahrq.gov/issue/bias…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43502/psn-pdf
    September 10, 2014 - Catastrophic medical malpractice payouts in the United States. September 10, 2014 Bixenstine PJ, Shore AD, Mehtsun WT, et al. Catastrophic Medical Malpractice Payouts in the United States. J Healthc Qual. 2013;36(4):43-53. doi:10.1111/jhq.12011. https://psnet.ahrq.gov/issue/catastrophic-medical-malpractice-payouts…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843320/psn-pdf
    February 01, 2023 - Society for Maternal-Fetal Medicine Special Statement: telemedicine in obstetrics-quality and safety considerations. February 1, 2023 Healy A, Davidson C, Allbert J, et al. Society for Maternal-Fetal Medicine Special Statement: telemedicine in obstetrics-quality and safety considerations. Am J Obstet Gynecol. 2023…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60053/psn-pdf
    January 01, 2021 - A review of adverse event reports from emergency departments in the Veterans Health Administration. March 18, 2020 Gill S, Mills PD, Watts BV, et al. A Review of Adverse Event Reports From Emergency Departments in the Veterans Health Administration. J Patient Saf. 2021;17(8):e898-e903. doi:10.1097/pts.0000000000000…

  9. Visiting Nurse Service of New York | Digital Healthcare Research

    digital.ahrq.gov/organization/visiting-nurse-service-new-york
    January 01, 2023 - Visiting Nurse Service of New York Development of Dashboards to Provide Feedback to Home Care Nurses Description This project designed and conducted a usability evaluation of dashboards that provide feedback to home care nurses to improve the care of patients with chronic hear…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34735/psn-pdf
    June 16, 2014 - An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS Chaired by the Chief Medical Officer. June 16, 2014 Donaldson L. London, UK: The Stationery Office, 2000. https://psnet.ahrq.gov/issue/organisation-memory-report-expert-group-learning-adverse-events-nhs- chaired-ch…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39032/psn-pdf
    September 19, 2016 - The natural history of recovery for the healthcare provider "second victim" after adverse patient events. September 19, 2016 Scott SD, Hirschinger LE, Cox KR, et al. The natural history of recovery for the healthcare provider "second victim" after adverse patient events. Qual Saf Health Care. 2009;18(5):325-330. d…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847543/psn-pdf
    April 12, 2023 - What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. April 12, 2023 Schnipper JL, Reyes Nieva H, Yoon CS, et al. What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. BMJ Qual Saf. 2023;32(8):457-469. doi:10.1136/bmjqs-2022- 0…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46588/psn-pdf
    February 28, 2018 - The relationship between resident burnout and safety- related and acceptability-related quality of healthcare: a systematic literature review. February 28, 2018 Dewa CS, Loong D, Bonato S, et al. The relationship between resident burnout and safety-related and acceptability-related quality of healthcare: a systema…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44246/psn-pdf
    November 15, 2016 - RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. November 15, 2016 Boston, MA: National Patient Safety Foundation; 2015. https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm The National Patient Safety Foundation issued these guidelines for improving root cause a…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44117/psn-pdf
    December 04, 2016 - The TRANSFORM patient safety project: a microsystem approach to improving outcomes on inpatient units. December 4, 2016 Braddock CH, Szaflarski N, Forsey L, et al. The TRANSFORM Patient Safety Project: a microsystem approach to improving outcomes on inpatient units. J Gen Intern Med. 2015;30(4):425-33. doi:10.1007…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60045/psn-pdf
    March 18, 2020 - Making Healthcare Safer III. March 18, 2020 Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF. https://psnet.ahrq.gov/issue/making-healthcare-safer-iii This newly issued follow up to the seminal AHRQ Making Health Care Safer rep…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/859346/psn-pdf
    January 01, 2024 - Sleep deprivation and medication administration errors in registered nurses- a scoping review. December 20, 2023 Martin CV, Joyce?McCoach J, Peddle M, et al. Sleep deprivation and medication administration errors in registered nurses- a scoping review. J Clin Nurs. 2024;33(3):859-873. doi:10.1111/jocn.16912. https…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34710/psn-pdf
    February 18, 2011 - Fatigue among clinicians and the safety of patients. February 18, 2011 Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. New Engl J Med. 2002;347(16):1249-1255. https://psnet.ahrq.gov/issue/fatigue-among-clinicians-and-safety-patients Acknowledging the inevitable connection b…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851921/psn-pdf
    August 02, 2023 - Association between electronic health record implementations and hospital-acquired conditions in pediatric hospitals. August 2, 2023 Rabbani N, Pageler NM, Hoffman JM, et al. Association between electronic health record implementations and hospital-acquired conditions in pediatric hospitals. Appl Clin Inform. 2023…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836728/psn-pdf
    March 15, 2022 - Survey suggests disrespectful behaviors persist in healthcare: practitioners speak up (yet again) – Parts I and II. March 15, 2022 ISMP Medication Safety Alert! Acute care edition. February 24, 2022; 27(4):1-5; March 10, 2022; 27(5):1-5. https://psnet.ahrq.gov/issue/survey-suggests-disrespectful-behaviors-persist-…
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