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psnet.ahrq.gov/node/36826/psn-pdf
December 31, 2014 - Staying safe: simple tools for safe surgery.
December 31, 2014
Karl RC. Staying safe: simple tools for safe surgery. Bull Am Coll Surg. 2007;92(4):16-22.
https://psnet.ahrq.gov/issue/staying-safe-simple-tools-safe-surgery
The author uses examples from his experience as a pilot to discuss aviation safety strategies,…
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psnet.ahrq.gov/node/42983/psn-pdf
June 27, 2018 - Medication reconciliation: getting started with IT.
June 27, 2018
Lefeber J
https://psnet.ahrq.gov/issue/medication-reconciliation-getting-started-it
This article reveals the experience of a critical access hospital that used medication reconciliation to
expand electronic health record adoption efforts. The author…
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psnet.ahrq.gov/perspective/lesson-vas-team-training-program
November 01, 2011 - Simulation accelerates expertise by providing experiences through scenarios that help to connect and … These types of experiences create self-regulation. Always thinking about what you're thinking.
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psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
March 27, 2024 - Family members report experiences of poor information sharing and little shared decision-making during … parents have described pediatric interfacility transfers as a time fraught with poor family-centered care experiences
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psnet.ahrq.gov/node/837913/psn-pdf
August 31, 2022 - Family members report experiences of poor
information sharing and little shared decision-making during … have described pediatric interfacility transfers as a time fraught with poor family-centered care
experiences
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psnet.ahrq.gov/node/38864/psn-pdf
July 08, 2013 - Addressing the quality and safety gap—parts I-III.
July 8, 2013
Princeton, NJ: Robert Wood Johnson Foundation; November 2010.
https://psnet.ahrq.gov/issue/addressing-quality-and-safety-gap-parts-i-iii
Part I of this three-part series examines the quality improvement experience of four health care
organizations and…
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psnet.ahrq.gov/node/39725/psn-pdf
August 11, 2010 - The Invisible Gorilla: and Other Ways Our Intuitions
Deceive Us.
August 11, 2010
Chabris C, Simons D. New York, NY: Crown Publishing Group; 2010. ISBN: 0307459659.
https://psnet.ahrq.gov/issue/invisible-gorilla-and-other-ways-our-intuitions-deceive-us
This book explores inattentional blindness, as demonstrated in …
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psnet.ahrq.gov/node/35062/psn-pdf
June 22, 2009 - Blurring the boundaries: scenario-based simulation in a
clinical setting.
June 22, 2009
Kneebone RL, Kidd J, Nestel D, et al. Blurring the boundaries: scenario-based simulation in a clinical
setting. Med Educ. 2005;39(6). doi:10.1111/j.1365-2929.2005.02110.x.
https://psnet.ahrq.gov/issue/blurring-boundaries-scen…
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psnet.ahrq.gov/node/60754/psn-pdf
August 05, 2020 - COVID blindness.
August 5, 2020
Brown L. COVID blindness. Diagnosis (Berl). 2020;7(2):83-84. doi:10.1515/dx-2020-0042.
https://psnet.ahrq.gov/issue/covid-blindness
This editorial describes one clinician’s experience treating a patient during the early stages of the COVID-
19 pandemic, and the impacts of “COVID bli…
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psnet.ahrq.gov/node/42186/psn-pdf
April 24, 2013 - High reliability: truly achieving healthcare quality and
safety.
April 24, 2013
Kaplan GS. Pursuing the perfect patient experience. Front Health Serv Manage. 2013;29(3):16-27.
https://psnet.ahrq.gov/issue/high-reliability-truly-achieving-healthcare-quality-and-safety
This commentary discusses how high reliability …
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psnet.ahrq.gov/node/42295/psn-pdf
May 29, 2013 - Medication reconciliation meets its MATCH.
May 29, 2013
Agency for Healthcare Research and Quality. Research Activities. May 2013:1, 3-4.
https://psnet.ahrq.gov/issue/medication-reconciliation-meets-its-match
This newsletter article describes the development of the Medications at Transitions and Clinical Handoffs
…
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psnet.ahrq.gov/node/46769/psn-pdf
November 07, 2018 - The Kentucky Institute for Patient Safety and Quality.
November 7, 2018
Kentucky Institute for Patient Safety and Quality; KIPSQ.
https://psnet.ahrq.gov/issue/kentucky-institute-patient-safety-and-quality
The Kentucky Institute for Patient Safety and Quality offers the support of a patient safety organization and
…
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psnet.ahrq.gov/node/38348/psn-pdf
December 30, 2014 - Implementing a bar-code medication administration
system.
December 30, 2014
Weber RJ. Implementing a Bar-Code Medication Administration System. Hosp Pharm. 2010;43(12):1016-
1022. doi:10.1310/hpj4312-1016.
https://psnet.ahrq.gov/issue/implementing-bar-code-medication-administration-system
This commentary discusse…
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psnet.ahrq.gov/node/34716/psn-pdf
February 18, 2011 - Facing our mistakes.
February 18, 2011
Hilfiker D. Facing our mistakes. N Engl J Med. 1984;310(2):118-22.
https://psnet.ahrq.gov/issue/facing-our-mistakes
In this piece, Dr. Hilfiker shares his personal experience with medical error. He describes the emotional toll
of these mistakes and the difficulty processing t…
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psnet.ahrq.gov/node/35214/psn-pdf
June 24, 2009 - Using clinical simulation to teach patient safety in an
acute/critical care nursing course.
June 24, 2009
Henneman EA, Cunningham H. Using clinical simulation to teach patient safety in an acute/critical care
nursing course. Nurse Educ. 2005;30(4):172-177.
https://psnet.ahrq.gov/issue/using-clinical-simulation-tea…
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psnet.ahrq.gov/node/37213/psn-pdf
October 13, 2011 - Human patient simulation: teaching students to provide
safe care.
October 13, 2011
Henneman EA, Cunningham H, Roche JP, et al. Human patient simulation: teaching students to provide
safe care. Nurse Educ. 2007;32(5):212-7.
https://psnet.ahrq.gov/issue/human-patient-simulation-teaching-students-provide-safe-care
T…
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psnet.ahrq.gov/node/37070/psn-pdf
April 21, 2011 - Excessive work hours of physicians in training in El
Salvador: putting patients at risk.
April 21, 2011
Taylor KRF. Excessive work hours of physicians in training in El Salvador: putting patients at risk. PLoS
Med. 2007;4(7):e205.
https://psnet.ahrq.gov/issue/excessive-work-hours-physicians-training-el-salvador-pu…
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psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
October 31, 2023 - SPOTLIGHT CASE
Robotic Surgery: Risks vs. Rewards
Citation Text:
Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/issue/organisational-readiness-exploring-preconditions-success-organisation-wide-patient-safety
February 01, 2011 - Study
Organisational readiness: exploring the preconditions for success in organisation-wide patient safety improvement programmes.
Citation Text:
Burnett S, Benn J, Pinto A, et al. Organisational readiness: exploring the preconditions for success in organisation-wide patient safety im…
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psnet.ahrq.gov/issue/how-unprofessional-behaviours-between-healthcare-staff-threaten-patient-care-and-safety
July 24, 2024 - Commentary
How unprofessional behaviours between healthcare staff threaten patient care and safety.
Citation Text:
Aunger J, Maben J, Westbrook JI. How unprofessional behaviours between healthcare staff threaten patient care and safety. Expert Rev Pharmacoecon Outcomes Res. 2025;Epub Jan…