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psnet.ahrq.gov/node/47621/psn-pdf
May 11, 2019 - 2018 update on pediatric medical overuse: a review.
May 11, 2019
Coon ER, Quinonez RA, Morgan DJ, et al. 2018 Update on Pediatric Medical Overuse: A Review. JAMA
Pediatr. 2019;173(4):379-384. doi:10.1001/jamapediatrics.2018.5550.
https://psnet.ahrq.gov/issue/2018-update-pediatric-medical-overuse-review
Overuse of …
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psnet.ahrq.gov/node/38203/psn-pdf
November 05, 2008 - Addressing prehospital patient safety using the science
of injury prevention and control.
November 5, 2008
Meisel ZF, Hargarten S, Vernick J. Addressing prehospital patient safety using the science of injury
prevention and control. Prehosp Emerg Care. 2008;12(4):411-6. doi:10.1080/10903120802290851.
https://psnet.…
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psnet.ahrq.gov/node/36564/psn-pdf
January 12, 2011 - Preventing medication errors in hospitals through a
systems approach and technological innovation: a
prescription for 2010.
January 12, 2011
Crane J, Crane FG. Preventing medication errors in hospitals through a systems approach and
technological innovation: a prescription for 2010. Hosp Top. 2006;84(4):3-8.
http…
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psnet.ahrq.gov/node/41340/psn-pdf
January 03, 2017 - How to develop a second victim support program: a
toolkit for health care organizations.
January 3, 2017
Pratt SD, Kenney L, Scott SD, et al. How to develop a second victim support program: a toolkit for health
care organizations. Jt Comm J Qual Patient Saf. 2012;38(5):235-40, 193.
https://psnet.ahrq.gov/issue/how…
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psnet.ahrq.gov/node/42867/psn-pdf
February 13, 2014 - Medication regimen complexity and hospital readmission
for an adverse drug event.
February 13, 2014
Willson MN, Greer CL, Weeks DL. Medication regimen complexity and hospital readmission for an adverse
drug event. Ann Pharmacother. 2014;48(1):26-32. doi:10.1177/1060028013510898.
https://psnet.ahrq.gov/issue/medica…
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psnet.ahrq.gov/node/38698/psn-pdf
June 10, 2009 - Towards a framework to select techniques for error
prediction: supporting novice users in the healthcare
sector.
June 10, 2009
Lyons M. Towards a framework to select techniques for error prediction: supporting novice users in the
healthcare sector. Appl Ergon. 2009;40(3):379-95. doi:10.1016/j.apergo.2008.11.004.
…
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psnet.ahrq.gov/node/46284/psn-pdf
January 01, 2021 - The consequences of whistle-blowing: an integrative
review.
July 26, 2017
Lim CR, Zhang MWB, Hussain SF, et al. The Consequences of Whistle-blowing: An Integrative Review. J
Patient Saf. 2021;17(6):e497-e502. doi:10.1097/PTS.0000000000000396.
https://psnet.ahrq.gov/issue/consequences-whistle-blowing-integrative-re…
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psnet.ahrq.gov/node/35846/psn-pdf
July 22, 2010 - Why worry? Worry, risk perceptions, and willingness to
act to reduce medical errors.
July 22, 2010
Peters E, Slovic P, Hibbard JH, et al. Why worry? Worry, risk perceptions, and willingness to act to reduce
medical errors. Health Psychology. 2006;25(2). doi:10.1037/0278-6133.25.2.144.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/35989/psn-pdf
September 17, 2010 - Using preprinted medication order forms to improve the
safety of investigational drug use.
September 17, 2010
Tamer H, Shehab N. Using preprinted medication order forms to improve the safety of investigational drug
use. Am J Health Syst Pharm. 2006;63(11):1022, 1025-1026, 1028.
https://psnet.ahrq.gov/issue/using-p…
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psnet.ahrq.gov/node/43315/psn-pdf
May 10, 2016 - Chief resident for quality improvement and patient safety:
a description.
May 10, 2016
Cox LAM, Fanucchi LC, Sinex NC, et al. Chief resident for quality improvement and patient safety: a
description. Am J Med. 2014;127(6):565-8. doi:10.1016/j.amjmed.2014.02.034.
https://psnet.ahrq.gov/issue/chief-resident-quality-…
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psnet.ahrq.gov/node/36610/psn-pdf
January 14, 2011 - Prevent medication errors: a New Year's resolution:
teaching patients about their medications.
January 14, 2011
Polzien G. Prevent medication errors: A New Year's resolution: teaching patients about their medications.
Home Healthc Nurse. 2007;25(1):59-62.
https://psnet.ahrq.gov/issue/prevent-medication-errors-new-…
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psnet.ahrq.gov/node/44875/psn-pdf
March 02, 2016 - "Teach-back" from a patient's perspective.
March 2, 2016
Miller S, Lattanzio M, Cohen S. "Teach-back" from a patient's perspective. Nursing (Brux). 2016;46(2):63-4.
doi:10.1097/01.NURSE.0000476249.18503.f5.
https://psnet.ahrq.gov/issue/teach-back-patients-perspective
The teach-back method, having patients repeat i…
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psnet.ahrq.gov/node/40549/psn-pdf
November 13, 2011 - Interdisciplinary team training identifies discrepancies in
institutional policies and practices.
November 13, 2011
Andreatta P, Frankel J, Smith SB, et al. Interdisciplinary team training identifies discrepancies in
institutional policies and practices. Am J Obstet Gynecol. 2011;205(4):298-301.
doi:10.1016/j.ajog…
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psnet.ahrq.gov/node/45241/psn-pdf
October 31, 2023 - Hospital Harm Project.
October 31, 2023
Canadian Institute for Health Information, Health Excellence Canada.
https://psnet.ahrq.gov/issue/hospital-harm-project
Reducing preventable harm associated with health care is a worldwide goal. This Canadian initiative
developed a measure to track unintended harm in acute c…
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psnet.ahrq.gov/node/36288/psn-pdf
December 23, 2016 - Preventing adverse events caused by emergency
electrical power system failures.
December 23, 2016
Preventing adverse events caused by emergency electrical power system failures. Sentinel Event Alert.
2006;37(37):1-3.
https://psnet.ahrq.gov/issue/preventing-adverse-events-caused-emergency-electrical-power-system-
…
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psnet.ahrq.gov/node/37039/psn-pdf
September 14, 2007 - Corporate Responsibility and Health Care Quality: A
Resource for Health Care Boards of Directors.
September 14, 2007
Callender AN, Hastings DA, Hemsley MC, et al. Washington DC: Office of the Inspector General of the US
Department of Health and Human Services, American Health Lawyers Association; September 2007.
h…
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psnet.ahrq.gov/node/43495/psn-pdf
December 15, 2014 - Disruptive behaviors among physicians.
December 15, 2014
Sanchez LT. Disruptive behaviors among physicians. JAMA. 2014;312(21):2209-2210.
doi:10.1001/jama.2014.10218.
https://psnet.ahrq.gov/issue/disruptive-behaviors-among-physicians
This commentary spotlights concerns about physicians with disruptive behaviors an…
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psnet.ahrq.gov/node/45265/psn-pdf
July 13, 2016 - Tackling disrespectful, unprofessional provider
behaviors.
July 13, 2016
Tackling Disrespectful, Unprofessional Provider Behaviors. ED Manage. 2016;28(6):S1-S4.
https://psnet.ahrq.gov/issue/tackling-disrespectful-unprofessional-provider-behaviors
Disrespectful conduct among health care providers can hinder safe ca…
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www.ahrq.gov/teamstepps-program/curriculum/implement/pre-ready.html
January 01, 2024 - Teaching Pre-Implementation Readiness
Present Slide 10, "Assessing Your Readiness"; note the importance of objectively assessing whether an organization is ready to implement TeamSTEPPS. Have people share times when their organizations attempted a change they weren’t really prepared for.
Using Slide 11, “…
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psnet.ahrq.gov/node/43217/psn-pdf
May 28, 2014 - Bullying: a hidden threat to patient safety.
May 28, 2014
Longo J, Hain D. Bullying: a hidden threat to patient safety. Nephrol Nurs J. 2014;41(2):193-99; quiz 200.
https://psnet.ahrq.gov/issue/bullying-hidden-threat-patient-safety
This commentary relates how bullying and other disruptive behaviors remain a pervasi…