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psnet.ahrq.gov/node/47418/psn-pdf
September 19, 2018 - How communications issues between doctors and nurses
can affect your health.
September 19, 2018
Howley EK. US News & World Report. September 5, 2018.
https://psnet.ahrq.gov/issue/how-communications-issues-between-doctors-and-nurses-can-affect-your-
health
Communication failures in health care routinely challenge …
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psnet.ahrq.gov/node/50887/psn-pdf
February 12, 2020 - Lessons learned from a systems approach to engaging
patients and families in patient safety transformation.
February 12, 2020
Hatlie MJ, Nahum A, Leonard R, et al. Lessons Learned from a Systems Approach to Engaging Patients
and Families in Patient Safety Transformation. Jt Comm J Qual Patient Saf. 2020;46(3):158-1…
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psnet.ahrq.gov/node/45795/psn-pdf
May 24, 2017 - Patient Hand-Off iNitiation and Evaluation (PHONE) study:
a randomized trial of patient handoff methods.
May 24, 2017
Clanton J, Gardner A, Subichin M, et al. Patient Hand-Off iNitiation and Evaluation (PHONE) study: A
randomized trial of patient handoff methods. Am J Surg. 2017;213(2):299-306.
doi:10.1016/j.amjsu…
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psnet.ahrq.gov/node/72779/psn-pdf
February 24, 2021 - Implementation of simulation training during the COVID-
19 pandemic: a New York hospital experience.
February 24, 2021
Pan D, Rajwani K. Implementation of simulation training during the COVID-19 pandemic: a New York
hospital experience. Simul Healthc. 2020;16(1):46-51. doi:10.1097/sih.0000000000000535.
https://psn…
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psnet.ahrq.gov/node/44742/psn-pdf
January 06, 2016 - A piece of my mind. From shame to guilt to love.
January 6, 2016
Pronovost P, Bienvenu J. A piece of my mind. From shame to guilt to love. JAMA. 2015;314(23):2507-
2508. doi:10.1001/jama.2015.11521.
https://psnet.ahrq.gov/issue/piece-my-mind-shame-guilt-love
While numerous studies have examined the psychological i…
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psnet.ahrq.gov/node/44921/psn-pdf
March 02, 2016 - Effective Board Governance of Safe Care: A (Theoretically
Underpinned) Cross-sectioned Examination of the
Breadth and Depth of Relationships through National
Quantitative Surveys and In-depth Qualitative Case
Studies.
March 2, 2016
Mannion R, Freeman T, Millar R, Davies H. Health and Social Care Delivery Research…
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psnet.ahrq.gov/node/50630/psn-pdf
November 06, 2019 - Non-dispensing pharmacists' actions and solutions of
drug therapy problems among elderly polypharmacy
patients in primary care.
November 6, 2019
Hazen ACM, Zwart DLM, Poldervaart JM, et al. Non-dispensing pharmacists' actions and solutions of drug
therapy problems among elderly polypharmacy patients in primary car…
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psnet.ahrq.gov/node/45617/psn-pdf
November 30, 2016 - Walking a tightrope: balancing the risk of diagnostic error
in inpatient pediatrics.
November 30, 2016
Berkwitt A, Osborn R, Grossman M. Walking a Tightrope: Balancing the Risk of Diagnostic Error in
Inpatient Pediatrics. Hosp Pediatr. 2016;6(9):566-8. doi:10.1542/hpeds.2016-0043.
https://psnet.ahrq.gov/issue/walk…
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psnet.ahrq.gov/node/846149/psn-pdf
March 15, 2023 - Medication errors in community pharmacies: evaluation
of a standardized safety program.
March 15, 2023
Ledlie S, Gomes T, Dolovich L, et al. Medication errors in community pharmacies: evaluation of a
standardized safety program. Explor Res Clin Soc Pharm. 2023;9:100218.
doi:10.1016/j.rcsop.2022.100218.
https://ps…
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psnet.ahrq.gov/node/73863/psn-pdf
September 22, 2021 - Electronic health record interoperability-why
electronically discontinued medications are still
dispensed.
September 22, 2021
Shervani S, Madden W, Gleason LJ. Electronic health record interoperability-why electronically
discontinued medications are still dispensed. JAMA Intern Med. 2021;181(10):1383-1384.
doi:10…
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psnet.ahrq.gov/node/47659/psn-pdf
January 27, 2019 - Medical overuse as a physician cognitive error: looking
under the hood.
January 27, 2019
Korenstein D. Medical overuse as a physician cognitive error: looking under the hood. JAMA Intern Med.
2019;179(1):26-27. doi:10.1001/jamainternmed.2018.5136.
https://psnet.ahrq.gov/issue/medical-overuse-physician-cognitive-er…
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psnet.ahrq.gov/node/46273/psn-pdf
August 30, 2017 - Increasing patient safety with neonates via handoff
communication during delivery: a call for
interprofessional health care team training across GME
and CME.
August 30, 2017
Vanderbilt AA, Pappada SM, Stein H, et al. Increasing patient safety with neonates via handoff
communication during delivery: a call for int…
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psnet.ahrq.gov/node/851460/psn-pdf
July 19, 2023 - Patient perceptions and experiences with medication-
related activities in the emergency department: a
qualitative study.
July 19, 2023
Zahl-Holmstad B, Garcia BH, Johnsgård T, et al. Patient perceptions and experiences with medication-
related activities in the emergency department: a qualitative study. BMJ Open …
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psnet.ahrq.gov/node/50414/psn-pdf
September 04, 2019 - Rating the raters: an evaluation of publicly reported
hospital quality rating systems.
September 4, 2019
Bilimoria KY, Birkmeyer JD, Burstin H, et al. NEJM Catalyst. August 14, 2019.
https://psnet.ahrq.gov/issue/rating-raters-evaluation-publicly-reported-hospital-quality-rating-systems
Numerous publicly available …
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psnet.ahrq.gov/node/46970/psn-pdf
June 27, 2018 - Using drug knowledgebase information to distinguish
between look-alike-sound-alike drugs.
June 27, 2018
Cheng CM, Salazar A, Amato MG, et al. Using drug knowledgebase information to distinguish between
look-alike-sound-alike drugs. J Am Med Inform Assoc. 2018;25(7):872-884. doi:10.1093/jamia/ocy043.
https://psnet.…
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psnet.ahrq.gov/node/45924/psn-pdf
March 15, 2017 - Patient safety incidents are common in primary care: a
national prospective active incident reporting survey.
March 15, 2017
Michel P, Brami J, Chanelière M, et al. Patient safety incidents are common in primary care: A national
prospective active incident reporting survey. PLoS One. 2017;12(2):e0165455.
doi:10.13…
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psnet.ahrq.gov/node/60336/psn-pdf
May 13, 2020 - Selecting Safe and Easier to Use Products for Healthcare
Using Human Factors Specification and Checklists.
May 13, 2020
Buckinghamshire, UK. Clinical Human Factors Group. April 2020.
https://psnet.ahrq.gov/issue/selecting-safe-and-easier-use-products-healthcare-using-human-factors-
specification-and
Poor eq…
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psnet.ahrq.gov/node/60603/psn-pdf
June 17, 2020 - Promoting psychosocial well-being of health care staff
during crisis.
June 17, 2020
Promoting psychosocial well-being of health care staff during crisis.
https://psnet.ahrq.gov/issue/promoting-psychosocial-well-being-health-care-staff-during-crisis
Effective practice in times of crisis is reliant on a workforce th…
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psnet.ahrq.gov/node/50429/psn-pdf
September 04, 2019 - Is disruptive behavior inherent to the surgeon or the
environment? Analysis of 314 events at a single academic
medical center.
September 4, 2019
Heslin MJ, Singletary BA, Benos KC, et al. Is Disruptive Behavior Inherent to the Surgeon or the
Environment? Analysis of 314 Events at a Single Academic Medical Center. …
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psnet.ahrq.gov/node/43998/psn-pdf
May 28, 2015 - Bridging the gap between hospital and primary care: the
pharmacist home visit.
May 28, 2015
Ensing HT, Koster ES, Stuijt CCM, et al. Bridging the gap between hospital and primary care: the
pharmacist home visit. Int J Clin Pharm. 2015;37(3):430-4. doi:10.1007/s11096-015-0093-4.
https://psnet.ahrq.gov/issue/bridgin…