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psnet.ahrq.gov/node/837795/psn-pdf
August 10, 2022 - Role of the regulator in enabling a just culture: a
qualitative study in mental health and hospital care.
August 10, 2022
Weenink J-W, Wallenburg I, Hartman L, et al. Role of the regulator in enabling a just culture: a qualitative
study in mental health and hospital care. BMJ Open. 2022;12(7):e061321. doi:10.1136/b…
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psnet.ahrq.gov/node/47382/psn-pdf
August 29, 2018 - Parenteral opioid shortage—treating pain during the
opioid-overdose epidemic.
August 29, 2018
Bruera E. Parenteral Opioid Shortage - Treating Pain during the Opioid-Overdose Epidemic. N Engl J Med.
2018;379(7):601-603. doi:10.1056/NEJMp1807117.
https://psnet.ahrq.gov/issue/parenteral-opioid-shortage-treating-pain-…
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psnet.ahrq.gov/node/46024/psn-pdf
June 15, 2017 - Introductions during time-outs: do surgical team
members know one another's names?
June 15, 2017
Birnbach DJ, Rosen LF, Fitzpatrick M, et al. Introductions during time-outs: do surgical team members
know one another's names? Jt Comm J Qual Patient Saf. 2017;43(6):284-288.
doi:10.1016/j.jcjq.2017.03.001.
https://p…
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psnet.ahrq.gov/node/72521/psn-pdf
December 02, 2020 - I-PASS illness diversity identifies patients at risk for
overnight clinical deterioration.
December 2, 2020
Shah C, Sanber K, Jacobson R, et al. I-PASS illness diversity identifies patients at risk for overnight clinical
deterioration. J Grad Med Educ. 2020;12(5):578-582. doi:10.4300/jgme-d-19-00755.1.
https://psn…
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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…
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psnet.ahrq.gov/node/837640/psn-pdf
July 06, 2022 - Identifying and reconciling patients' allergy information
within the electronic health record.
July 6, 2022
Vallamkonda S, Ortega CA, Lo YC, et al. Identifying and reconciling patients' allergy information within the
electronic health record. Stud Health Technol Inform. 2022;290:120-124. doi:10.3233/shti220044.
ht…
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psnet.ahrq.gov/node/36237/psn-pdf
September 12, 2011 - An empirically derived taxonomy of factors affecting
physicians' willingness to disclose medical errors.
September 12, 2011
Kaldjian LC, Jones EW, Rosenthal GE, et al. An empirically derived taxonomy of factors affecting
physicians’ willingness to disclose medical errors. J Gen Intern Med. 2007;21(9). doi:10.1007/b…
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psnet.ahrq.gov/node/43709/psn-pdf
December 04, 2014 - A team-based approach to reducing cardiac monitor
alarms.
December 4, 2014
Dandoy CE, Davies SM, Flesch L, et al. A team-based approach to reducing cardiac monitor alarms.
Pediatrics. 2014;134(6):e1686-e1694. doi:10.1542/peds.2014-1162.
https://psnet.ahrq.gov/issue/team-based-approach-reducing-cardiac-monitor-alar…
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psnet.ahrq.gov/node/44590/psn-pdf
November 11, 2015 - Physician motivation: listening to what pay-for-
performance programs and quality improvement
collaboratives are telling us.
November 11, 2015
Herzer KR, Pronovost P. Physician Motivation: Listening to What Pay-for-Performance Programs and
Quality Improvement Collaboratives Are Telling Us. Jt Comm J Qual Patient S…
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psnet.ahrq.gov/node/60180/psn-pdf
April 01, 2020 - Incidence of wrong-site surgery list errors for a 2-year
period in a single national health service board.
April 1, 2020
Geraghty A, Ferguson L, McIlhenny C, et al. Incidence of wrong-site surgery list errors for a 2-year period
in a single national health service board. J Patient Saf. 2020;16(1):79-83.
doi:10.109…
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psnet.ahrq.gov/node/851920/psn-pdf
August 02, 2023 - "You just want to feel safe when you go to a healthcare
professional:" intimate partner violence and patient
safety.
August 2, 2023
Maras SA. “You just want to feel safe when you go to a healthcare professional:” Intimate partner violence
and patient safety. Soc Sci Med. 2023;331:116066. doi:10.1016/j.socscimed.20…
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psnet.ahrq.gov/node/60361/psn-pdf
May 20, 2020 - Novel, High-Impact Studies Evaluating Health System and
Healthcare Professional Responsiveness to COVID-19
(R01).
May 20, 2020
Rockville, MD: Agency for Healthcare Research and Quality; May 14, 2020.
https://psnet.ahrq.gov/issue/novel-high-impact-studies-evaluating-health-system-and-healthcare-
professional-respo…
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psnet.ahrq.gov/node/45746/psn-pdf
December 14, 2016 - Moving toward improved teamwork in cancer care: the
role of psychological safety in team communication.
December 14, 2016
Jain AK, Fennell ML, Chagpar AB, et al. Moving Toward Improved Teamwork in Cancer Care: The Role of
Psychological Safety in Team Communication. J Oncol Pract. 2016;12(11):1000-1011.
https://psn…
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psnet.ahrq.gov/node/45701/psn-pdf
December 21, 2016 - Clinical decision support for drug related events: moving
towards better prevention.
December 21, 2016
Kane-Gill SL, Achanta A, Kellum JA, et al. Clinical decision support for drug related events: Moving towards
better prevention. World J Crit Care Med. 2016;5(4):204-211.
https://psnet.ahrq.gov/issue/clinical-deci…
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psnet.ahrq.gov/node/47190/psn-pdf
January 01, 2021 - Disclosure coaching: an ask-tell-ask model to support
clinicians in disclosure conversations.
July 25, 2018
Shapiro J, Robins L, Galowitz P, et al. Disclosure Coaching: An Ask-Tell-Ask Model to Support Clinicians in
Disclosure Conversations. J Patient Saf. 2021;17(8):e1364-e1370. doi:10.1097/PTS.0000000000000491.
…
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psnet.ahrq.gov/node/74692/psn-pdf
January 26, 2022 - Changes made to orders placed by overnight admitting
residents on teaching rounds the next day.
January 26, 2022
Chiel L, Freiman E, Yarahuan J, et al. Changes made to orders placed by overnight admitting residents on
teaching rounds the next day. Hosp Pediatr. 2021;12(1):e35-e38. doi:10.1542/hpeds.2021-005823.
ht…
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psnet.ahrq.gov/node/45137/psn-pdf
May 18, 2016 - Less is more: a project to reduce the number of PIMs
(potentially inappropriate medications) on an elderly care
ward.
May 18, 2016
Aung TH, Beck AJ, Siese T, et al. Less is more: a project to reduce the number of PIMs (potentially
inappropriate medications) on an elderly care ward. BMJ Qual Improv Rep. 2016;5(1).
…
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psnet.ahrq.gov/node/47849/psn-pdf
August 14, 2019 - The effect of external inspections on safety in acute
hospitals in the National Health Service in England: a
controlled interrupted time-series analysis.
August 14, 2019
Castro-Avila A, Bloor K, Thompson C. The effect of external inspections on safety in acute hospitals in the
National Health Service in England: A…
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psnet.ahrq.gov/node/46201/psn-pdf
September 27, 2017 - Risk factors for patient-reported errors during cancer
follow-up: results from a national survey in Denmark.
September 27, 2017
Christiansen AH, Lipczak H, Knudsen JL, et al. Risk factors for patient-reported errors during cancer follow-
up: Results from a national survey in Denmark. Cancer Epidemiol. 2017;49:38-45…
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psnet.ahrq.gov/node/44692/psn-pdf
January 27, 2016 - Good people who try their best can have problems:
recognition of human factors and how to minimise error.
January 27, 2016
Brennan PA, Mitchell DA, Holmes S, et al. Good people who try their best can have problems: recognition
of human factors and how to minimise error. Br J Oral Maxillofac Surg. 2016;54(1):3-7.
d…