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psnet.ahrq.gov/node/837674/psn-pdf
July 13, 2022 - Differences between managers’ and safety professionals’
perceptions of upwards influence attempts within safety
practice.
July 13, 2022
Madigan C, Way KA, Johnstone K, et al. Differences between managers’ and safety professionals’
perceptions of upwards influence attempts within safety practice. J Safety Res. 2022…
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psnet.ahrq.gov/node/43426/psn-pdf
July 03, 2016 - Discussing the undiscussable with the powerful: why and
how faculty must learn to counteract organizational
silence.
July 3, 2016
Dankoski ME, Bickel J, Gusic ME. Discussing the undiscussable with the powerful: why and how faculty
must learn to counteract organizational silence. Acad Med. 2014;89(12):1610-3.
doi:…
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psnet.ahrq.gov/node/836836/psn-pdf
March 30, 2022 - Deficiencies after the New Electronic Health Record Go-
Live at the Mann-Grandstaff VA Medical Center in
Spokane, WA.
March 30, 2022
Washington, DC: VA Office of Inspector General; March 17, 2022.
https://psnet.ahrq.gov/issue/deficiencies-after-new-electronic-health-record-go-live-mann-grandstaff-va-
medical-cent…
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www.ahrq.gov/topics/long-term-care.html
Topic: Long-Term Care
AHRQ has toolkits, recommendations, and other resources for long-term care facilities, such as nursing homes and rehabilitation centers, to improve quality, reduce errors, and increase patient safety.
AHRQ Research Findings Support Effort to Reduce Pre…
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psnet.ahrq.gov/node/866586/psn-pdf
August 28, 2024 - Hidden flaws behind expert-level accuracy of multimodal
GPT-4 vision in medicine.
August 28, 2024
Jin Q, Chen F, Zhou Y, et al. Hidden flaws behind expert-level accuracy of multimodal GPT-4 vision in
medicine. NPJ Dig Med. 2024;7(1):190. doi:10.1038/s41746-024-01185-7.
https://psnet.ahrq.gov/issue/hidden-flaws-beh…
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psnet.ahrq.gov/node/47030/psn-pdf
June 06, 2018 - Creating a safer operating room: groups, team dynamics
and crew resource management principles.
June 6, 2018
Wakeman D, Langham MR. Creating a safer operating room: Groups, team dynamics and crew resource
management principles. Semin Pediatr Surg. 2018;27(2):107-113. doi:10.1053/j.sempedsurg.2018.02.008.
https://p…
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psnet.ahrq.gov/node/844995/psn-pdf
February 22, 2023 - Diagnostic delays among COVID-19 patients with a
second concurrent diagnosis.
February 22, 2023
Freund O, Azolai L, Sror N, et al. Diagnostic delays among COVID?19 patients with a second concurrent
diagnosis. J Hosp Med. 2023;18(4):321-328. doi:10.1002/jhm.13063.
https://psnet.ahrq.gov/issue/diagnostic-delays-amon…
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psnet.ahrq.gov/node/47263/psn-pdf
January 01, 2021 - Dissecting communication barriers in healthcare: a path
to enhancing communication resiliency, reliability, and
patient safety.
November 28, 2018
Guttman OT, Lazzara EH, Keebler JR, et al. Dissecting Communication Barriers in Healthcare: A Path to
Enhancing Communication Resiliency, Reliability, and Patient Safety…
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psnet.ahrq.gov/node/61101/psn-pdf
November 04, 2020 - Investigation into Management of Venous
Thromboembolism Risk in Patients Following
Thrombolysis for an Acute Stroke.
November 4, 2020
Farnborough, UK; Healthcare Safety Investigation Branch. October 2020
https://psnet.ahrq.gov/issue/investigation-management-venous-thromboembolism-risk-patients-following-
thrombol…
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psnet.ahrq.gov/node/837421/psn-pdf
June 15, 2022 - Are personal health records (PHRs) facilitating patient
safety? A scoping review.
June 15, 2022
Joseph AL, Monkman H, Kushniruk AW, et al. Are personal health records (PHRs) facilitating patient
safety? A scoping review. Stud Health Technol Inform. 2022;2022:535-539. doi:10.3233/shti220516.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/860718/psn-pdf
January 17, 2024 - Impact of hospital accreditation on quality improvement
in healthcare: a systematic review.
January 17, 2024
Alhawajreh MJ, Paterson AS, Jackson WJ. Impact of hospital accreditation on quality improvement in
healthcare: a systematic review. PLoS ONE. 2023;18(12):e0294180. doi:10.1371/journal.pone.0294180.
https://…
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psnet.ahrq.gov/node/860732/psn-pdf
April 16, 2024 - Retained Swabs Following Invasive Procedures: Themes
Identified from a Review of NHS Serious Incident Reports.
April 16, 2024
Dorset, UK: Health Services Safety Investigations Body; April 2024.
https://psnet.ahrq.gov/issue/retained-swabs-following-invasive-procedures-themes-identified-review-nhs-
serious-incident
…
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psnet.ahrq.gov/node/44037/psn-pdf
March 14, 2018 - Pediatric medication safety in the emergency department.
March 14, 2018
Benjamin L, Frush K, Shaw KN, et al. Pediatric Medication Safety in the Emergency Department. Ann
Emerg Med. 2018;71(3):e17-e24. doi:10.1016/j.annemergmed.2017.12.013.
https://psnet.ahrq.gov/issue/pediatric-medication-safety-emergency-departmen…
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psnet.ahrq.gov/node/45943/psn-pdf
March 15, 2017 - Identifying and reducing complications after emergency
room discharge.
March 15, 2017
Hofmann PB, Bagian JP. Patient Saf Qual Healthc. February 20, 2017.
https://psnet.ahrq.gov/issue/identifying-and-reducing-complications-after-emergency-room-discharge
Emergency departments are complex environments that harbor fac…
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psnet.ahrq.gov/node/861277/psn-pdf
January 24, 2024 - Clinical deterioration as a nurse sensitive indicator in the
out-of-hospital context: a scoping review.
January 24, 2024
Mccullough K, Baker M, Bloxsome D, et al. Clinical deterioration as a nurse sensitive indicator in the out?of
?hospital context: a scoping review. J Clin Nurs. 2024;33(3):874-889. doi:10.1111/joc…
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psnet.ahrq.gov/node/856637/psn-pdf
November 29, 2023 - Deficiencies in Quality Management Processes and
Delays in the Communication of Test Results and Follow-
Up Care at the Phoenix VA Health Care System in Arizona.
November 29, 2023
Washington DC; VA Office of the Inspector General; October 31, 2023; Report no. 22-03599-07.
https://psnet.ahrq.gov/issue/deficiencies-…
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psnet.ahrq.gov/node/36583/psn-pdf
January 14, 2011 - The effect of workload on infection risk in critically ill
patients.
January 14, 2011
Hugonnet S, Chevrolet J-C, Pittet D. The effect of workload on infection risk in critically ill patients. Crit
Care Med. 2007;35(1):76-81.
https://psnet.ahrq.gov/issue/effect-workload-infection-risk-critically-ill-patients
Lower…
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psnet.ahrq.gov/node/45304/psn-pdf
June 28, 2017 - Nurses' perceived skills and attitudes about updated
safety concepts: impact on medication administration
errors and practices.
June 28, 2017
Armstrong GE, Dietrich M, Norman L, et al. Nurses? Perceived Skills and Attitudes About Updated Safety
Concepts. J Nurs Care Qual. 2016;32(3):226-233. doi:10.1097/ncq.000000…
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psnet.ahrq.gov/node/861778/psn-pdf
January 31, 2024 - Care Deficiencies and Leaders' Inadequate Reviews of a
Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA
Medical Center in Memphis, Tennessee.
January 31, 2024
Washington, DC: The Veterans Affairs Inspector General; January 10, 2024. Report No. 23-00777-52.
https://psnet.ahrq.gov/issue/care-deficiencies-and-l…
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psnet.ahrq.gov/node/845073/psn-pdf
February 22, 2023 - Nursing student errors and near misses: three years of
data.
February 22, 2023
Silvestre JH, Spector ND. Nursing student errors and near misses: three years of data. J Nurs Educ.
2023;62(1):12-19. doi:10.3928/01484834-20221109-05.
https://psnet.ahrq.gov/issue/nursing-student-errors-and-near-misses-three-years-data…