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psnet.ahrq.gov/node/860390/psn-pdf
January 10, 2024 - Key factors for effective implementation of healthcare
workers support interventions after patient safety
incidents in health organisations: a scoping review.
January 10, 2024
Guerra-Paiva S, Lobão MJ, Simões DG, et al. Key factors for effective implementation of healthcare
workers support interventions after pati…
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psnet.ahrq.gov/node/854262/psn-pdf
October 04, 2023 - Five strategies for how patients and families can improve
patient safety: World Patient Safety Day 2023.
October 4, 2023
Wu AW, Papieva I, Sheridan S, et al. Five strategies for how patients and families can improve patient
safety: World Patient Safety Day 2023. J Patient Saf Risk Manag. 2023;28(4):147-152.
doi:10…
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psnet.ahrq.gov/node/867445/psn-pdf
January 08, 2025 - Using human factors methods to mitigate bias in artificial
intelligence-based clinical decision support.
January 8, 2025
Militello LG, Diiulio J, Wilson DL, et al. Using human factors methods to mitigate bias in artificial
intelligence-based clinical decision support. J Am Med Inform Assoc. 2025;32(2):398-403.
doi…
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psnet.ahrq.gov/node/867641/psn-pdf
February 26, 2025 - Open disclosure among general practitioners as second
victim of a patient safety incident: a cross-sectional study
in Flanders (Belgium).
February 26, 2025
Neyens L, Stouten E, Vanhaecht K, et al. Open disclosure among general practitioners as second victim of
a patient safety incident: a cross-sectional study in …
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psnet.ahrq.gov/node/848361/psn-pdf
May 03, 2023 - More than algorithms: an analysis of safety events
involving ML-enabled medical devices reported to the
FDA.
May 3, 2023
Lyell D, Wang Y, Coiera E, et al. More than algorithms: an analysis of safety events involving ML-enabled
medical devices reported to the FDA. J Am Med Inform Assoc. 2023;30(7):1227-1236.
doi:1…
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psnet.ahrq.gov/node/37292/psn-pdf
May 24, 2015 - Guilty, afraid, and alone — struggling with medical error.
May 24, 2015
Delbanco T, Bell SK. Guilty, afraid, and alone--struggling with medical error. N Engl J Med.
2007;357(17):1682-3.
https://psnet.ahrq.gov/issue/guilty-afraid-and-alone-struggling-medical-error
Disclosure of medical errors remains an important a…
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psnet.ahrq.gov/node/836926/psn-pdf
April 13, 2022 - Overall performance of a drug-drug interaction clinical
decision support system: quantitative evaluation and end-
user survey.
April 13, 2022
Van De Sijpe G, Quintens C, Walgraeve K, et al. Overall performance of a drug–drug interaction clinical
decision support system: quantitative evaluation and end-user survey.…
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www.ahrq.gov/hai/tools/abate/skills.html
March 01, 2022 - Adherence and Skills Assessment
This toolkit provides documents for assessing whether staff are adhering to the decolonization protocol. These documents include self-administered survey questions for patients to describe their bathing experience, as well as staff skills assessment questions for peer or supervis…
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psnet.ahrq.gov/node/45205/psn-pdf
July 11, 2017 - Performance of the Global Assessment of Pediatric
Patient Safety (GAPPS) tool.
July 11, 2017
Landrigan CP, Stockwell DC, Toomey SL, et al. Performance of the Global Assessment of Pediatric Patient
Safety (GAPPS) Tool. Pediatrics. 2016;137(6). doi:10.1542/peds.2015-4076.
https://psnet.ahrq.gov/issue/performance-glo…
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psnet.ahrq.gov/node/45969/psn-pdf
January 07, 2019 - The surgeon as the second victim? Results of the Boston
Intraoperative Adverse Events Surgeons' Attitude (BISA)
study.
January 7, 2019
Han K, Bohnen JD, Peponis T, et al. The surgeon as the second victim? Results of the Boston
Intraoperative Adverse Events Surgeons' Attitude (BISA) study. J Am Coll Surg. 2017;224(…
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psnet.ahrq.gov/node/74718/psn-pdf
February 02, 2022 - Medication-related interventions to improve medication
safety and patient outcomes on transition from adult
intensive care settings: a systematic review and meta-
analysis.
February 2, 2022
Bourne RS, Jennings JK, Panagioti M, et al. Medication-related interventions to improve medication safety
and patient outcom…
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psnet.ahrq.gov/node/837797/psn-pdf
August 10, 2022 - Toward constructive change after making a medical error:
recovery from situations of error theory as a psychosocial
model for clinician recovery.
August 10, 2022
Harrison R, Johnson J, Mcmullan RD, et al. Toward constructive change after making a medical error:
recovery from situations of error theory as a psychos…
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psnet.ahrq.gov/node/841769/psn-pdf
December 21, 2022 - Negative emotions experienced by healthcare staff
following medication administration errors: a descriptive
study using text-mining and content analysis of incident
data.
December 21, 2022
Mahat S, Rafferty AM, Vehviläinen-Julkunen K, et al. Negative emotions experienced by healthcare staff
following medication a…
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psnet.ahrq.gov/node/43635/psn-pdf
November 12, 2014 - Electronic medical record: a balancing act of patient
safety, privacy and health care delivery.
November 12, 2014
Gummadi S, Housri N, Zimmers TA, et al. Electronic medical record: a balancing act of patient safety,
privacy and health care delivery. Am J Med Sci. 2014;348(3):238-243.
doi:10.1097/MAJ.00000000000002…
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psnet.ahrq.gov/node/47097/psn-pdf
June 26, 2018 - Patterns of potential opioid misuse and subsequent
adverse outcomes in Medicare, 2008 to 2012.
June 26, 2018
Carey CM, Jena AB, Barnett ML. Patterns of Potential Opioid Misuse and Subsequent Adverse Outcomes
in Medicare, 2008 to 2012. Ann Intern Med. 2018;168(12):837-845. doi:10.7326/M17-3065.
https://psnet.ahrq.g…
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psnet.ahrq.gov/issue/youre-boss-hospital
February 28, 2024 - Newspaper/Magazine Article
You're the boss at the hospital.
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November 28, 2016
This article shares guidelines for accompanying a fa…
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www.ahrq.gov/talkingquality/translate/organize/type.html
February 01, 2016 - Organizing Quality Measures by Type
The oldest categorization of health care quality measures was created by Avedis Donabedian when he distinguished between measures of structure, process, and outcome. [1] More recently, patient experience and cost measures have been added to those being considered. Many peopl…
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psnet.ahrq.gov/node/47118/psn-pdf
August 08, 2018 - Wrong-site nerve blocks: a systematic literature review to
guide principles for prevention.
August 8, 2018
Deutsch ES, Yonash RA, Martin DE, et al. Wrong-site nerve blocks: A systematic literature review to guide
principles for prevention. J Clin Anesth. 2018;46:101-111. doi:10.1016/j.jclinane.2017.12.008.
https:/…
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psnet.ahrq.gov/node/60571/psn-pdf
June 10, 2020 - Going to the COVID-19 Gemba: using observation and
high reliability strategies to achieve safety in a time of
crisis.
June 10, 2020
Thull-Freedman J, Mondoux S, Stang A, et al. Going to the COVID-19 Gemba: Using observation and high
reliability strategies to achieve safety in a time of crisis. CJEM. 2020;22(6):738…
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psnet.ahrq.gov/node/45350/psn-pdf
October 21, 2016 - A National Trauma Care System: Integrating Military and
Civilian Trauma Systems to Achieve Zero Preventable
Deaths After Injury.
October 21, 2016
National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press;
2016.
https://psnet.ahrq.gov/issue/national-trauma-care-system-inte…