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psnet.ahrq.gov/node/856584/psn-pdf
January 01, 2024 - Patient safety incidents in endoscopy: a human factors
analysis of non-procedural significant harm incidents
from the National Reporting and Learning System (NRLS).
November 29, 2023
Ravindran S, Matharoo M, Rutter MD, et al. Patient safety incidents in endoscopy: a human factors
analysis of nonprocedural signific…
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psnet.ahrq.gov/node/43378/psn-pdf
August 14, 2014 - Interventions to reduce pediatric medication errors: a
systematic review.
August 14, 2014
Rinke ML, Bundy DG, Velasquez CA, et al. Interventions to reduce pediatric medication errors: a
systematic review. Pediatrics. 2014;134(2):338-360. doi:10.1542/peds.2013-3531.
https://psnet.ahrq.gov/issue/interventions-reduce…
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psnet.ahrq.gov/node/45375/psn-pdf
September 27, 2016 - Association of a web-based handoff tool with rates of
medical errors.
September 27, 2016
Mueller SK, Yoon CS, Schnipper JL. Association of a Web-Based Handoff Tool With Rates of Medical
Errors. JAMA Intern Med. 2016;176(9):1400-2. doi:10.1001/jamainternmed.2016.4258.
https://psnet.ahrq.gov/issue/association-web-ba…
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psnet.ahrq.gov/node/45509/psn-pdf
September 28, 2016 - Computerized triggers of big data to detect delays in
follow-up of chest imaging results.
September 28, 2016
Murphy DR, Meyer AND, Bhise V, et al. Computerized Triggers of Big Data to Detect Delays in Follow-up
of Chest Imaging Results. Chest. 2016;150(3):613-20. doi:10.1016/j.chest.2016.05.001.
https://psnet.ahrq…
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psnet.ahrq.gov/node/41795/psn-pdf
September 07, 2016 - Drug shortage-associated increase in catheter-related
blood stream infection in children.
September 7, 2016
Ralls MW, Blackwood A, Arnold MA, et al. Drug shortage-associated increase in catheter-related blood
stream infection in children. Pediatrics. 2012;130(5):e1369-73. doi:10.1542/peds.2011-3894.
https://psnet.…
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psnet.ahrq.gov/node/861772/psn-pdf
January 31, 2024 - Rapid expansion of the Healing Emotional Lives of Peers
program during COVID-19: a second victim peer support
program for healthcare professionals.
January 31, 2024
Rivera-Chiauzzi EY, Huang L, Osborne AK, et al. Rapid expansion of the Healing Emotional Lives of Peers
program during COVID-19: a second victim peer …
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psnet.ahrq.gov/node/40526/psn-pdf
June 15, 2011 - Critical drug–drug interactions for use in electronic health
records systems with computerized physician order
entry: review of leading approaches.
June 15, 2011
Classen DC, Phansalkar S, Bates DW. Critical Drug-Drug Interactions for Use in Electronic Health Records
Systems With Computerized Physician Order Entry.…
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psnet.ahrq.gov/node/42068/psn-pdf
April 09, 2013 - Wisdom through adversity: learning and growing in the
wake of an error.
April 9, 2013
Plews-Ogan M, Owens JE, May NB. Wisdom through adversity: learning and growing in the wake of an
error. Patient Educ Couns. 2013;91(2):236-42. doi:10.1016/j.pec.2012.12.006.
https://psnet.ahrq.gov/issue/wisdom-through-adversity-l…
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psnet.ahrq.gov/node/41986/psn-pdf
January 23, 2013 - Slow progress on meeting hospital safety standards:
learning from the Leapfrog Group's efforts.
January 23, 2013
Moran J, Scanlon D. Slow progress on meeting hospital safety standards: learning from the Leapfrog
Group's efforts. Health Aff (Millwood). 2013;32(1):27-35. doi:10.1377/hlthaff.2011.0056.
https://psnet.…
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psnet.ahrq.gov/node/48187/psn-pdf
August 21, 2019 - How medical error shapes physicians' perceptions of
learning: an exploratory study.
August 21, 2019
Shepherd L, LaDonna KA, Cristancho SM, et al. How Medical Error Shapes Physicians' Perceptions of
Learning: An Exploratory Study. Acad Med. 2019;94(8):1157-1163. doi:10.1097/ACM.0000000000002752.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/45889/psn-pdf
August 16, 2017 - New persistent opioid use after minor and major surgical
procedures in US adults.
August 16, 2017
Brummett CM, Waljee JF, Goesling J, et al. New Persistent Opioid Use After Minor and Major Surgical
Procedures in US Adults. JAMA Surg. 2017;152(6):e170504. doi:10.1001/jamasurg.2017.0504.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/40978/psn-pdf
March 21, 2012 - Relationship between patient safety and hospital surgical
volume.
March 21, 2012
Hernandez-Boussard T, Downey JR, McDonald KM, et al. Relationship between Patient Safety and
Hospital Surgical Volume. Health Serv Res. 2011;47(2). doi:10.1111/j.1475-6773.2011.01310.x.
https://psnet.ahrq.gov/issue/relationship-betwee…
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psnet.ahrq.gov/node/841202/psn-pdf
December 18, 2024 - Updated Results for the AHRQ Surveys on Patient Safety
Culture Workplace Safety Supplemental Item Set for
Hospitals.
December 18, 2024
Tyler ER, Yalden O, Fan L, et al. Results For The Ahrq Surveys On Patient Safety Culture (Sops)
Workplace Safety Supplemental Item Set For Hospitals. Agency for Healthcare Research…
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psnet.ahrq.gov/node/42023/psn-pdf
May 25, 2013 - Description and evaluation of adaptations to the Global
Trigger Tool to enhance value to adverse event reduction
efforts.
May 25, 2013
Kennerly DA, Saldaña M, Kudyakov R, et al. Description and evaluation of adaptations to the global trigger
tool to enhance value to adverse event reduction efforts. J Patient Saf. …
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psnet.ahrq.gov/node/42803/psn-pdf
February 13, 2014 - Pilot testing of a model for insurer-driven, large-scale
multicenter simulation training for operating room teams.
February 13, 2014
Arriaga AF, Gawande AA, Raemer D, et al. Pilot testing of a model for insurer-driven, large-scale
multicenter simulation training for operating room teams. Ann Surg. 2014;259(3):403-1…
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psnet.ahrq.gov/node/47905/psn-pdf
April 03, 2019 - Ranking hospitals based on preventable hospital death
rates: a systematic review with implications for both
direct measurement and indirect measurement through
standardized mortality rates.
April 3, 2019
Manaseki-Holland S, Lilford RJ, Te AP, et al. Ranking Hospitals Based on Preventable Hospital Death
Rates: A S…
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psnet.ahrq.gov/node/41225/psn-pdf
March 29, 2012 - The impact of perioperative catastrophes on
anesthesiologists: results of a national survey.
March 29, 2012
Gazoni FM, Amato PE, Malik ZM, et al. The impact of perioperative catastrophes on anesthesiologists:
results of a national survey. Anesth Analg. 2012;114(3):596-603. doi:10.1213/ANE.0b013e318227524e.
https:/…
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psnet.ahrq.gov/node/45333/psn-pdf
September 21, 2016 - Association of inpatient hospital experience with patient
safety indicators: a cross-sectional, Canadian study.
September 21, 2016
Kemp KA, Santana MJ, Southern DA, et al. Association of inpatient hospital experience with patient safety
indicators: a cross-sectional, Canadian study. BMJ Open. 2016;6(7):e011242. doi…
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psnet.ahrq.gov/node/45437/psn-pdf
September 01, 2018 - Decreasing malpractice claims by reducing preventable
perinatal harm.
September 1, 2018
Riley W, Meredith LW, Price R, et al. Decreasing Malpractice Claims by Reducing Preventable Perinatal
Harm. Health Serv Res. 2016;51(suppl 3):2453-2471. doi:10.1111/1475-6773.12551.
https://psnet.ahrq.gov/issue/decreasing-malpr…
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psnet.ahrq.gov/issue/final-check-say-it-out-loud
July 31, 2023 - Multi-use Website
The Final Check: Say it Out Loud.
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August 1, 2012
This Web site provides resources to help reduce incidence of …