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psnet.ahrq.gov/node/39712/psn-pdf
July 02, 2014 - Swapping horses midstream: factors related to
physicians' changing their minds about a diagnosis.
July 2, 2014
Eva KW, Link CL, Lutfey KE, et al. Swapping horses midstream: factors related to physicians' changing
their minds about a diagnosis. Acad Med. 2010;85(7):1112-7. doi:10.1097/ACM.0b013e3181e16103.
https://…
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psnet.ahrq.gov/node/863220/psn-pdf
February 28, 2024 - Second-victim phenomenon.
February 28, 2024
New L, Lambeth T. Second-victim phenomenon. Nurs Clin North Am. 2024;59(1):141-152.
doi:10.1016/j.cnur.2023.11.011.
https://psnet.ahrq.gov/issue/second-victim-phenomenon
The second victim phenomenon (SVP) refers to clinicians who experience continued psychological harm
…
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psnet.ahrq.gov/node/37652/psn-pdf
September 24, 2010 - Case study: getting boards on board at Allen Memorial
Hospital, Iowa Health System.
September 24, 2010
Slessor SR, Crandall JB, Nielsen GA. Case study: getting boards on board at Allen Memorial Hospital,
Iowa Health System. Jt Comm J Qual Patient Saf. 2008;34(4):221-227.
https://psnet.ahrq.gov/issue/case-study-get…
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psnet.ahrq.gov/node/36547/psn-pdf
January 10, 2011 - The power of collaboration with patient safety programs:
building safe passage for patients, nurses, and clinical
staff.
January 10, 2011
Kerfoot KM, Rapala K, Ebright PR, et al. The power of collaboration with patient safety programs: building
safe passage for patients, nurses, and clinical staff. J Nurs Adm. 200…
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psnet.ahrq.gov/node/35317/psn-pdf
July 14, 2009 - Accreditation Council on Graduate Medical Education
technical skills competency compliance: urologic surgical
skills.
July 14, 2009
Hammond L, Ketchum J, Schwartz BF. Accreditation Council on Graduate Medical Education Technical
Skills Competency Compliance: Urologic Surgical Skills. J Am Coll Surg. 2005;201(3).
…
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psnet.ahrq.gov/node/42018/psn-pdf
February 27, 2013 - Scale, nature, preventability and causes of adverse
events in hospitalised older patients.
February 27, 2013
Merten H, Zegers M, de Bruijne M, et al. Scale, nature, preventability and causes of adverse events in
hospitalised older patients. Age Ageing. 2013;42(1):87-93. doi:10.1093/ageing/afs153.
https://psnet.ahr…
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psnet.ahrq.gov/node/47164/psn-pdf
January 01, 2022 - Quality Improvement Series.
February 25, 2019
British Medical Journal. 2022.
https://psnet.ahrq.gov/issue/quality-improvement-series
Efforts to enhance safety and quality are integrated into daily work in health care, but improvements are not
being realized as quickly as desired. This compiled series of articles h…
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psnet.ahrq.gov/node/45835/psn-pdf
February 01, 2017 - Deploying and measuring a risk and patient safety
program.
February 1, 2017
Orel H, McGroarty M, Marchegiani H. Deploying and measuring a risk and patient safety program. J
Healthc Risk Manag. 2017;36(3):26-33. doi:10.1002/jhrm.21266.
https://psnet.ahrq.gov/issue/deploying-and-measuring-risk-and-patient-safety-pro…
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psnet.ahrq.gov/node/35410/psn-pdf
September 11, 2009 - Intravenous medication safety and smart infusion
systems: lessons learned and future opportunities.
September 11, 2009
Keohane C, Hayes J, Saniuk C, et al. Intravenous medication safety and smart infusion systems: lessons
learned and future opportunities. J Infus Nurs. 2005;28(5):321-328.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/42732/psn-pdf
May 05, 2014 - Reducing falls and fall-related injuries in mental health: a
1-year multihospital falls collaborative.
May 5, 2014
Quigley PA, Barnett SD, Bulat T, et al. Reducing falls and fall-related injuries in mental health: a 1-year
multihospital falls collaborative. J Nurs Care Qual. 2014;29(1):51-9.
doi:10.1097/01.NCQ.000…
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psnet.ahrq.gov/node/44567/psn-pdf
October 14, 2015 - The misery of a doctor's first days.
October 14, 2015
Hester JL. The Atlantic. October 1, 2015.
https://psnet.ahrq.gov/issue/misery-doctors-first-days
Although there is no consensus regarding whether the "July effect" actually exists, it is not hard to imagine
the difficulties associated with the first days of pra…
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psnet.ahrq.gov/node/38219/psn-pdf
May 24, 2015 - The emotional impact of medical error involvement on
physicians: a call for leadership and organisational
accountability.
May 24, 2015
Schwappach DL, Boluarte TA. The emotional impact of medical error involvement on physicians: a call for
leadership and organisational accountability. Swiss Med Wkly. 2009;139(1-2):…
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psnet.ahrq.gov/node/38487/psn-pdf
March 18, 2009 - Competence and certification of registered nurses and
safety of patients in intensive care units.
March 18, 2009
Kendall-Gallagher D, Blegen MA. Competence and certification of registered nurses and safety of patients
in intensive care units. Am J Crit Care. 2009;18(2):106-113; quiz 114. doi:10.4037/ajcc2009487.
h…
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psnet.ahrq.gov/node/60309/psn-pdf
May 06, 2020 - COVID-19 leads to increased need for dialysis machines.
May 6, 2020
Mosley T. Here & Now. Boston Public Radio. April 27, 2020.
https://psnet.ahrq.gov/issue/covid-19-leads-increased-need-dialysis-machines
Comorbidities can result in unexpected care complexities. This article discusses an emerging challenge for
…
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psnet.ahrq.gov/node/38258/psn-pdf
April 14, 2011 - How often do physicians review medication charts on
ward rounds?
April 14, 2011
Looi KL, Black PN. How often do physicians review medication charts on ward rounds? BMC Clin
Pharmacol. 2008;8:9. doi:10.1186/1472-6904-8-9.
https://psnet.ahrq.gov/issue/how-often-do-physicians-review-medication-charts-ward-rounds
Thi…
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psnet.ahrq.gov/node/33726/psn-pdf
March 01, 2012 - principle, which was the most radical at the time, was by all means we should learn from
our patients' experiences … compensate when we've acted badly, to support our staff when
we've acted reasonably, and to learn from our experiences
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psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - July 6, 2022
Listening to women: recommendations from women of color to improve experiences … June 18, 2020
Information and power: women of color's experiences interacting with health
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psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
February 15, 2017 - January 10, 2024
Medical students' experiences, perceptions, and management of second
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psnet.ahrq.gov/node/33775/psn-pdf
December 01, 2014 - interventions.(11)
Third, facilitate spread of the patient safety efforts, allowing partnership implementation experiences
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psnet.ahrq.gov/web-mm/workaround-error
October 30, 2024 - September 4, 2016
Survey of nurses' experiences applying The Joint Commission's medication