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psnet.ahrq.gov/node/73386/psn-pdf
June 16, 2021 - Healthcare professionals' encounters with ethnic minority
patients: the critical incident approach.
June 16, 2021
Debesay J, Kartzow AH, Fougner M. Healthcare professionals’ encounters with ethnic minority patients: the
critical incident approach. Nurs Inq. 2021;29(1):e12421. doi:10.1111/nin.12421.
https://psnet.a…
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psnet.ahrq.gov/node/36199/psn-pdf
March 28, 2011 - Time of day effects on the incidence of anesthetic
adverse events.
March 28, 2011
Wright MC, Phillips-Bute B, Mark JB, et al. Time of day effects on the incidence of anesthetic adverse
events. Qual Saf Health Care. 2006;15(4):258-63.
https://psnet.ahrq.gov/issue/time-day-effects-incidence-anesthetic-adverse-events…
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psnet.ahrq.gov/node/47747/psn-pdf
March 13, 2019 - A piece of my mind. Hard times and hard stops.
March 13, 2019
Lifflander AL. Hard Times and Hard Stops. JAMA. 2019;321(9):837-838. doi:10.1001/jama.2019.1208.
https://psnet.ahrq.gov/issue/piece-my-mind-hard-times-and-hard-stops
Implementing new information systems can have unintended consequences on processes. This…
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psnet.ahrq.gov/node/866698/psn-pdf
September 11, 2024 - Can we ensure medication safety with the use of speech
recognition software?
September 11, 2024
Can we ensure medication safety with the use of speech recognition software? ISMP Medication Safety
Alert! Acute Care. August 22, 2024;29(17):1-3.
https://psnet.ahrq.gov/issue/can-we-ensure-medication-safety-use-speech-…
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psnet.ahrq.gov/node/47367/psn-pdf
October 15, 2018 - Themed Issue on Innovations in Medication Safety.
October 15, 2018
Kane-Gill SL. Innovations in Medication Safety: Services and Technologies to Enhance the Understanding
and Prevention of Adverse Drug Reactions. Pharmacotherapy. 2018;38(8):782-784.
doi:10.1002/phar.2154.
https://psnet.ahrq.gov/issue/themed-issue-i…
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psnet.ahrq.gov/node/72600/psn-pdf
December 23, 2020 - Improving hospital safety culture for falls prevention
through interdisciplinary health education.
December 23, 2020
Lopez-Jeng C, Eberth SD. Improving hospital safety culture for falls prevention through interdisciplinary
health education. Health Promot Pract. 2020;21(6):918-925. doi:10.1177/1524839919840337.
htt…
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psnet.ahrq.gov/node/60950/psn-pdf
September 23, 2020 - An effective intervention: limiting opioid prescribing as a
means of reducing opioid analgesic misuse, and
overdose deaths.
September 23, 2020
Fink BC, Uyttebrouck O, Larson RS. An effective intervention: limiting opioid prescribing as a means of
reducing opioid analgesic misuse, and overdose deaths. J Law Med Eth…
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psnet.ahrq.gov/node/46861/psn-pdf
February 28, 2018 - Special K with no license to kill: accidental ketamine
overdose on induction of general anesthesia.
February 28, 2018
Warner LL, Smischney N. Accidental Ketamine Overdose on Induction of General Anesthesia. Am J Case
Rep. 2018;19:10-12.
https://psnet.ahrq.gov/issue/special-k-no-license-kill-accidental-ketamine-ove…
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psnet.ahrq.gov/node/44455/psn-pdf
September 02, 2015 - Finding antecedents of psychological safety: a step
toward quality improvement.
September 2, 2015
Aranzamendez G, James D, Toms R. Finding Antecedents of Psychological Safety: A Step Toward Quality
Improvement. Nurs Forum. 2015;50(3):171-178. doi:10.1111/nuf.12084.
https://psnet.ahrq.gov/issue/finding-antecedents-…
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psnet.ahrq.gov/node/47638/psn-pdf
February 06, 2019 - Decreasing surgical site infections by developing a high
reliability culture.
February 6, 2019
Pettis AM. Decreasing Surgical Site Infections by Developing a High Reliability Culture. AORN J.
2018;108(6):644-650. doi:10.1002/aorn.12416.
https://psnet.ahrq.gov/issue/decreasing-surgical-site-infections-developing-hi…
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psnet.ahrq.gov/node/46475/psn-pdf
April 16, 2018 - Incident reporting behaviours following the Francis
report: a cross-sectional survey.
April 16, 2018
Archer G, Colhoun A. Incident reporting behaviours following the Francis report: A cross-sectional survey. J
Eval Clin Pract. 2017;24(2). doi:10.1111/jep.12849.
https://psnet.ahrq.gov/issue/incident-reporting-behav…
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psnet.ahrq.gov/node/72531/psn-pdf
January 01, 2021 - Factors influencing physician responsiveness to nurse-
initiated communication: a qualitative study.
December 2, 2020
Manojlovich M, Harrod M, Hofer TP, et al. Factors influencing physician responsiveness to nurse-initiated
communication: a qualitative study. BMJ Qual Saf. 2021;30(9):747-754. doi:10.1136/bmjqs-2020…
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www.ahrq.gov/patient-safety/reports/healthaffairs.html
March 01, 2019 - AHRQ-Funded Patient Safety Research Featured in Health Affairs
AHRQ-funded research studies focused on critical aspects of patient safety and health information technology were published in a November 2018 patient safety-themed issue of Health Affairs . As part of its commitment to lead patient-safety efforts …
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www.ahrq.gov/patient-safety/settings/esrd/resource/cultureofsafety.html
January 01, 2015 - Creating a Culture of Safety
ESRD Toolkit
The Creating a Culture of Safety module of the ESRD Toolkit discusses the importance of a comprehensive, unit-based approach to safety and its impact on improving patient care and reducing harm in dialysis centers.
Presentation Slides ( PPTX, 20 M B)
Facilitator …
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psnet.ahrq.gov/node/47879/psn-pdf
June 05, 2019 - The attitudes of nursing students and clinical instructors
towards reporting irregular incidents in the medical clinic.
June 5, 2019
Halperin O, Bronshtein O. The attitudes of nursing students and clinical instructors towards reporting
irregular incidents in the medical clinic. Nurse Educ Pract. 2019;36:34-39. doi:…
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psnet.ahrq.gov/node/854830/psn-pdf
January 01, 2024 - The effect of evidence in crisis learning: based on a
perspective integration framework.
October 25, 2023
Wang B, Li D, Wang Y. The effect of evidence in crisis learning: based on a perspective integration
framework. J Contingencies Crisis Manag. 2024;32(1):e12506. doi:10.1111/1468-5973.12506.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/837060/psn-pdf
May 11, 2022 - Clinician distress and inappropriate antibiotic prescribing
for acute respiratory tract infections: a retrospective
cohort study.
May 11, 2022
Brady KJS, Barlam TF, Trockel MT, et al. Clinician distress and inappropriate antibiotic prescribing for
acute respiratory tract infections: a retrospective cohort study. J…
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psnet.ahrq.gov/node/73316/psn-pdf
May 26, 2021 - Racial bias among emergency providers: strategies to
mitigate its adverse effects.
May 26, 2021
Brockett-Walker C, Lall M, Evans DD, et al. Racial bias among emergency providers: strategies to mitigate
its adverse effects. Adv Emerg Nurs J. 2021;43(2):89-101. doi:10.1097/tme.0000000000000352.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/44217/psn-pdf
November 10, 2015 - Assessing the potential adoption and usefulness of
concurrent, action-oriented, electronic adverse drug
event triggers designed for the outpatient setting.
November 10, 2015
Mull HJ, Rosen AK, Shimada SL, et al. Assessing the potential adoption and usefulness of concurrent,
action-oriented, electronic adverse drug…
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psnet.ahrq.gov/node/45343/psn-pdf
August 10, 2016 - Medication errors involving the intravenous
administration route: characteristics of voluntarily
reported medication errors.
August 10, 2016
Wolf ZR. Medication Errors Involving the Intravenous Administration Route: Characteristics of Voluntarily
Reported Medication Errors. J Infus Nurs. 2016;39(4):235-48. doi:10.…