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psnet.ahrq.gov/node/45674/psn-pdf
September 29, 2017 - Pain Management and Prescription Opioid-related Harms:
Exploring the State of the Evidence: Proceedings of a
Workshop—in Brief.
September 29, 2017
Forstag EH; Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid
Abuse; Health and Medicine Division. Washington, DC: National Academy …
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psnet.ahrq.gov/node/60614/psn-pdf
June 24, 2020 - A systems approach to analyzing and preventing hospital
adverse events.
June 24, 2020
Leveson N, Samost A, Dekker SWA, et al. A systems approach to analyzing and preventing hospital
adverse events. J Patient Saf. 2020;16(2):162-167. doi:10.1097/pts.0000000000000263.
https://psnet.ahrq.gov/issue/systems-approach-an…
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psnet.ahrq.gov/node/44804/psn-pdf
November 18, 2016 - The Safer Delivery of Surgical Services Program (S3):
explaining its differential effectiveness and exploring
implications for improving quality in complex systems.
November 18, 2016
Flynn LC, McCulloch P, Morgan LJ, et al. The Safer Delivery of Surgical Services Program (S3): Explaining
Its Differential Effective…
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psnet.ahrq.gov/node/60159/psn-pdf
March 25, 2020 - Root cause analyses of reported adverse events
occurring during gastrointestinal scope and tube
placement procedures in the Veterans Health Association.
March 25, 2020
Soncrant C, Mills PD, Neily J, et al. Root cause analyses of reported adverse events occurring during
gastrointestinal scope and tube placement pro…
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psnet.ahrq.gov/node/47151/psn-pdf
July 11, 2018 - Intravenous smart pumps: usability issues, intravenous
medication administration error, and patient safety.
July 11, 2018
Giuliano KK. Intravenous Smart Pumps: Usability Issues, Intravenous Medication Administration Error, and
Patient Safety. Crit Care Nurs Clin North Am. 2018;30(2):215-224. doi:10.1016/j.cnc.2018.…
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psnet.ahrq.gov/node/837208/psn-pdf
May 25, 2022 - Interprofessional model on speaking up behaviour in
healthcare professionals: a qualitative study.
May 25, 2022
Umoren R, Kim S, Gray MM, et al. Interprofessional model on speaking up behaviour in healthcare
professionals: a qualitative study. BMJ Lead. 2022;6(1):15-19. doi:10.1136/leader-2020-000407.
https://psne…
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psnet.ahrq.gov/node/46230/psn-pdf
September 24, 2017 - Challenges and opportunities from the Agency for
Healthcare Research and Quality (AHRQ) research
summit on improving diagnosis: a proceedings review.
September 24, 2017
Henriksen K, Dymek C, Harrison MI, et al. Challenges and opportunities from the Agency for Healthcare
Research and Quality (AHRQ) research summit …
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psnet.ahrq.gov/node/60792/psn-pdf
August 12, 2020 - Nurse workarounds in the electronic health record: an
integrative review.
August 12, 2020
Fraczkowski D, Matson J, Lopez KD. Nurse workarounds in the electronic health record: an integrative
review. J Am Med Inform Assoc. 2020;27(7):1149-1165. doi:10.1093/jamia/ocaa050.
https://psnet.ahrq.gov/issue/nurse-workaroun…
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psnet.ahrq.gov/node/73291/psn-pdf
May 19, 2021 - How can never event data be used to reflect or improve
hospital safety performance?
May 19, 2021
Olivarius?McAllister J, Pandit M, Sykes A, et al. How can never event data be used to reflect or improve
hospital safety performance? Anaesthesia. 2021;76(12):1616-1624. doi:10.1111/anae.15476.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/42300/psn-pdf
May 29, 2013 - Effect of noise on auditory processing in the operating
room.
May 29, 2013
Way J, Long A, Weihing J, et al. Effect of noise on auditory processing in the operating room. J Am Coll
Surg. 2013;216(5):933-8. doi:10.1016/j.jamcollsurg.2012.12.048.
https://psnet.ahrq.gov/issue/effect-noise-auditory-processing-operating…
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psnet.ahrq.gov/node/44092/psn-pdf
November 16, 2015 - Does lean management improve patient safety culture?
An extensive evaluation of safety culture in a
radiotherapy institute.
November 16, 2015
Simons P, Houben R, Vlayen A, et al. Does lean management improve patient safety culture? An extensive
evaluation of safety culture in a radiotherapy institute. Eur J Oncol …
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psnet.ahrq.gov/node/60689/psn-pdf
July 15, 2020 - The psychological and mental impact of coronavirus
disease 2019 (COVID-19) on medical staff and general
public - a systematic review and meta-analysis.
July 15, 2020
Luo M, Guo L, Yu M, et al. The psychological and mental impact of coronavirus disease 2019 (COVID-19)
on medical staff and general public – a systema…
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psnet.ahrq.gov/node/837025/psn-pdf
May 04, 2022 - Central venous catheter guidewire retention: lessons
from England's never event database.
May 4, 2022
Mariyaselvam MZA, Patel V, Young HE, et al. Central venous catheter guidewire retention: lessons from
England's never event database. J Patient Saf. 2022;18(2):e387-e392.
doi:10.1097/pts.0000000000000826.
https:/…
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psnet.ahrq.gov/node/47535/psn-pdf
November 07, 2018 - Gosport War Memorial Hospital. The Report of the
Gosport Independent Panel.
November 7, 2018
Gosport Independent Panel. London, England: Crown Copyright; 2018. ISBN: 9781528604062.
https://psnet.ahrq.gov/issue/gosport-war-memorial-hospital-report-gosport-independent-panel
Organizational culture influences how comf…
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psnet.ahrq.gov/node/37738/psn-pdf
January 10, 2017 - Recruitment of hospitals for a safety climate study:
facilitators and barriers.
January 10, 2017
Rosen AK, Gaba DM, Meterko M, et al. Recruitment of hospitals for a safety climate study: facilitators and
barriers. Jt Comm J Qual Patient Saf. 2008;34(5):275-84.
https://psnet.ahrq.gov/issue/recruitment-hospitals-saf…
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psnet.ahrq.gov/node/857581/psn-pdf
January 01, 2025 - Medicare and Medicaid Programs and the Children’s
Health Insurance Program; Hospital Inpatient Prospective
Payment Systems for Acute Care Hospitals and the Long-
Term Care Hospital Prospective Payment System and
Policy Changes and Fiscal Year 2025 Rates; Quality
Programs Requirements; and Other Policy Changes.
Au…
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psnet.ahrq.gov/node/37348/psn-pdf
March 28, 2012 - Impact of duty hours restrictions on quality of care and
clinical outcomes.
March 28, 2012
Bhavsar J, Montgomery D, Li J, et al. Impact of duty hours restrictions on quality of care and clinical
outcomes. Am J Med. 2007;120(11):968-74.
https://psnet.ahrq.gov/issue/impact-duty-hours-restrictions-quality-care-and-cl…
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psnet.ahrq.gov/node/60203/psn-pdf
April 08, 2020 - Is my patient ready for a safe transfer to a lower-intensity
care setting? Nursing complexity as an independent
predictor of adverse events risk after ICU discharge.
April 8, 2020
Sanson G, Marino C, Valenti A, et al. Is my patient ready for a safe transfer to a lower-intensity care
setting? Nursing complexity as …
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psnet.ahrq.gov/node/73438/psn-pdf
June 30, 2021 - Implementation of patient safety structures and
processes in the patient-centered medical home.
June 30, 2021
Oberlander T, Scholle SH, Marsteller JA, et al. Implementation of patient safety structures and processes in
the patient-centered medical home. J Healthc Qual. 2021;43(6):324-339.
doi:10.1097/jhq.000000000…
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psnet.ahrq.gov/node/45534/psn-pdf
October 12, 2016 - Can you multitask? Evidence and limitations of task
switching and multitasking in emergency medicine.
October 12, 2016
Skaugset M, Farrell S, Carney M, et al. Can You Multitask? Evidence and Limitations of Task Switching
and Multitasking in Emergency Medicine. Ann Emerg Med. 2016;68(2):189-95.
doi:10.1016/j.anneme…