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psnet.ahrq.gov/node/43121/psn-pdf
April 16, 2014 - Implementing the Safety Thermometer tool in one NHS
trust.
April 16, 2014
Buckley C, Cooney K, Sills E, et al. Implementing the Safety Thermometer tool in one NHS trust. Br J Nurs.
2014;23(5):268-72.
https://psnet.ahrq.gov/issue/implementing-safety-thermometer-tool-one-nhs-trust
This commentary details a National…
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psnet.ahrq.gov/node/47708/psn-pdf
February 13, 2019 - The role of purple pens in learning to prescribe.
February 13, 2019
Kinston R, McCarville N, Hassell A. The role of purple pens in learning to prescribe. Clin Teach.
2019;16(6):598-603. doi:10.1111/tct.12991.
https://psnet.ahrq.gov/issue/role-purple-pens-learning-prescribe
Interventions utilizing color as visual c…
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psnet.ahrq.gov/node/39695/psn-pdf
July 21, 2010 - The impact of the 80-hour work week on appropriate
resident case coverage.
July 21, 2010
Shin S, Britt R, Doviak M, et al. The Impact of the 80-Hour Work Week on Appropriate Resident Case
Coverage. Journal of Surgical Research. 2009;162(1). doi:10.1016/j.jss.2009.12.003.
https://psnet.ahrq.gov/issue/impact-80-hour…
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psnet.ahrq.gov/node/43043/psn-pdf
September 19, 2016 - "Second victim" casualties and how physician leaders
can help.
September 19, 2016
MacLeod L. "Second victim" casualties and how physician leaders can help. Physician Exect. 2014;40(1):8-
12.
https://psnet.ahrq.gov/issue/second-victim-casualties-and-how-physician-leaders-can-help
Second victims are clinicians who …
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psnet.ahrq.gov/node/851452/psn-pdf
July 19, 2023 - Factors influencing in-hospital prescribing errors: a
systematic review.
July 19, 2023
Mahomedradja RF, Schinkel M, Sigaloff KCE, et al. Factors influencing in?hospital prescribing errors: a
systematic review. Br J Clin Pharmacol. 2023;89(6):1724-1735. doi:10.1111/bcp.15694.
https://psnet.ahrq.gov/issue/factors-in…
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psnet.ahrq.gov/node/34946/psn-pdf
February 03, 2011 - Relationship of incorrect dosing of fibrinolytic therapy
and clinical outcomes.
February 3, 2011
Mehta RH. Relationship of Incorrect Dosing of Fibrinolytic Therapy and Clinical Outcomes. JAMA.
2005;293(14). doi:10.1001/jama.293.14.1746.
https://psnet.ahrq.gov/issue/relationship-incorrect-dosing-fibrinolytic-therap…
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psnet.ahrq.gov/node/43302/psn-pdf
August 21, 2014 - A medication-based trigger tool to identify adverse events
in pediatric anesthesiology.
August 21, 2014
Taghon T, Elsey N, Miler V, et al. A medication-based trigger tool to identify adverse events in pediatric
anesthesiology. Jt Comm J Qual Patient Saf. 2014;40(7):326-334.
https://psnet.ahrq.gov/issue/medication-…
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psnet.ahrq.gov/node/73615/psn-pdf
August 18, 2021 - Ripped apart: medical misdiagnosis and malpractice.
August 18, 2021
Kast S, Gerr M, Black D, et al. “On the Record.” WYPR. August 3, 2021
https://psnet.ahrq.gov/issue/ripped-apart-medical-misdiagnosis-and-malpractice
Misdiagnosis is a persistent challenge for patients and families to navigate. This audio news …
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psnet.ahrq.gov/node/44224/psn-pdf
June 10, 2015 - To be sued less, doctors should consider talking to
patients more.
June 10, 2015
Carroll AE.
https://psnet.ahrq.gov/issue/be-sued-less-doctors-should-consider-talking-patients-more
Reporting on trends associated with medical malpractice, how the same physicians tend to get sued, and
reasons patients file claims, …
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psnet.ahrq.gov/node/45832/psn-pdf
April 05, 2017 - Best Practices in Patient Safety: 2nd Global Ministerial
Summit on Patient Safety.
April 5, 2017
Federal Ministry of Health and World Health Organization: Bonn, Germany; March 2017.
https://psnet.ahrq.gov/issue/best-practices-patient-safety-2nd-global-ministerial-summit-patient-safety
This report summarizes a wide…
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psnet.ahrq.gov/node/45881/psn-pdf
March 15, 2017 - CE: nursing's evolving role in patient safety.
March 15, 2017
Kowalski SL, Anthony M. CE: Nursing's Evolving Role in Patient Safety. Am J Nurs. 2017;117(2):34-48.
doi:10.1097/01.NAJ.0000512274.79629.3c.
https://psnet.ahrq.gov/issue/ce-nursings-evolving-role-patient-safety
Nursing is a key component of patient care…
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psnet.ahrq.gov/node/37734/psn-pdf
April 30, 2008 - Improving the quality of written prescriptions in a general
hospital: the influence of 10 years of serial audits and
targeted interventions.
April 30, 2008
Gommans J, McIntosh P, Bee S, et al. Improving the quality of written prescriptions in a general hospital:
the influence of 10 years of serial audits and targe…
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psnet.ahrq.gov/node/33830/psn-pdf
March 22, 2016 - Measuring and Responding to Deaths From Medical
Errors
March 22, 2016
Ranji SR. Measuring and Responding to Deaths From Medical Errors. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors
Annual Perspective 2016
The Prevalence of Deaths Due to Preventable Adve…
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psnet.ahrq.gov/node/851870/psn-pdf
July 31, 2023 - intraorganizational learning is to let people know if you are making system
changes based on their experiences
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psnet.ahrq.gov/node/852700/psn-pdf
August 30, 2023 - We had weekly calls and huddles with colleagues who shared their experiences and lessons learned. … We have an implementation workgroup that is providing real-time feedback on their
experiences.
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psnet.ahrq.gov/node/49757/psn-pdf
April 01, 2016 - Situational Awareness and Patient Safety
April 1, 2016
Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
The Case
A 40-year-old woman with a history of cirrhosis and known esophageal varices was admitted to the hospit…
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psnet.ahrq.gov/node/837785/psn-pdf
August 05, 2022 - Emergence of Application-based Healthcare
August 5, 2022
Marvel FA, Dowell P, Mossburg SE. Emergence of Application-based Healthcare. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/emergence-application-based-healthcare
Introduction
The demand for digital healthcare, including both telemedicine and hea…
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psnet.ahrq.gov/node/49395/psn-pdf
April 01, 2003 - Medication Overdose
April 1, 2003
Kaushal R. Medication Overdose. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/medication-overdose
The Case
A 15-year-old boy with end-stage AIDS was admitted to the pediatric ICU with mental status changes. He
was diagnosed with status epilepticus and started on a loading…
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psnet.ahrq.gov/node/33766/psn-pdf
May 01, 2014 - In Conversation With… Didier Pittet, MD, MS
May 1, 2014
In Conversation With… Didier Pittet, MD, MS. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
Editor's note: Didier Pittet, MD, MS, is Professor of Medicine and Director of the Infection Control
Programme and WHO Co…
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psnet.ahrq.gov/node/867749/psn-pdf
March 12, 2025 - How unprofessional behaviours between healthcare staff
threaten patient care and safety.
March 12, 2025
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 30.
doi:10.1080/14737167.2025.2460518…