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psnet.ahrq.gov/node/43866/psn-pdf
January 28, 2015 - Inside Canada's secret world of medical error: 'There is a
lot of lying, there's a lot of cover-up.'
January 28, 2015
Blackwell T.
https://psnet.ahrq.gov/issue/inside-canadas-secret-world-medical-error-there-lot-lying-theres-lot-cover
Reporting on the lack of transparency around medical errors in Canada, this news…
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psnet.ahrq.gov/node/60227/psn-pdf
April 15, 2020 - The next step in learning from sentinel events in
healthcare.
April 15, 2020
Bos K, Dongelmans DA, Greuters S, et al. The next step in learning from sentinel events in healthcare.
BMJ Open Qual. 2020;9(1):e000739. doi:10.1136/bmjoq-2019-000739.
https://psnet.ahrq.gov/issue/next-step-learning-sentinel-events-health…
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psnet.ahrq.gov/node/40672/psn-pdf
September 03, 2011 - Didactic and simulation nontechnical skills team training
to improve perinatal patient outcomes in a community
hospital.
September 3, 2011
Riley W, Davis SE, Miller KK, et al. Didactic and simulation nontechnical skills team training to improve
perinatal patient outcomes in a community hospital. Jt Comm J Qual Pat…
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psnet.ahrq.gov/node/43749/psn-pdf
December 10, 2014 - Alarm management: first things first: using reliable data
to eliminate unnecessary alarms.
December 10, 2014
Vanderveen T. Patient Saf Qual Healthc. November/December 2014;11:38-40,42-45.
https://psnet.ahrq.gov/issue/alarm-management-first-things-first-using-reliable-data-eliminate-unnecessary-
alarms
Spotlightin…
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psnet.ahrq.gov/node/44002/psn-pdf
March 25, 2015 - Preventing medication errors in transitions of care: a
patient case approach.
March 25, 2015
Johnson A, Guirguis E, Grace Y. Preventing medication errors in transitions of care: A patient case
approach. J Am Pharm Assoc (2003). 2015;55(2):e264-276. doi:10.1331/JAPhA.2015.15509.
https://psnet.ahrq.gov/issue/prevent…
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psnet.ahrq.gov/web-mm/autopsy-revelation
December 01, 2007 - Autopsy Revelation
Citation Text:
Shojania KG. Autopsy Revelation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/33668/psn-pdf
May 01, 2008 - In Conversation with…David W. Bates, MD, MSc
May 1, 2008
In Conversation with…David W. Bates, MD, MSc. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
Editor's note: Dr. David Bates is a Professor at Harvard Medical School, Medical Director of Clinical and
Quality …
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psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-pandemic
October 30, 2024 - A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic
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April 27, 2022
Innovation
Conta…
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psnet.ahrq.gov/node/33744/psn-pdf
February 01, 2013 - In Conversation With… Beverley H. Johnson
February 1, 2013
In Conversation With… Beverley H. Johnson. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-beverley-h-johnson
Editor's note: Beverley H. Johnson is the President and Chief Executive Officer of the Institute for Patient-
and Family-…
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psnet.ahrq.gov/node/33754/psn-pdf
September 01, 2013 - In Conversation With… Sidney Dekker, MA, MSc, PhD
September 1, 2013
In Conversation With… Sidney Dekker, MA, MSc, PhD. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd
Editor's note: Sidney Dekker is Professor and Director of the Safety Science Innovation Lab at Grif…
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psnet.ahrq.gov/web-mm/unfamiliar-catheter
November 01, 2006 - The Unfamiliar Catheter
Citation Text:
Swayze SC, James A. The Unfamiliar Catheter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/innovations
February 26, 2025 - Innovations
The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …
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psnet.ahrq.gov/innovation/esimpler-dynamic-electronic-health-record-integrated-checklist-clinical-decision-support
June 16, 2021 - EMERGING INNOVATIONS
eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds.
Citation Text:
Geva A, Albert BD, Hamilton S, et al. eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support duri…
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psnet.ahrq.gov/node/60932/psn-pdf
January 01, 2021 - Retrospective analysis of reported suicide deaths and
attempts on Veterans Health Administration campuses
and inpatient units.
September 23, 2020
Mills PD, Soncrant C, Gunnar W. Retrospective analysis of reported suicide deaths and attempts on
Veterans Health Administration campuses and inpatient units. BMJ Qual S…
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psnet.ahrq.gov/node/42451/psn-pdf
August 07, 2013 - Is the Surgical Safety Checklist successfully conducted?
An observational study of social interactions in the
operating rooms of a tertiary hospital.
August 7, 2013
Cullati S, Le Du S, Raë A-C, et al. Is the Surgical Safety Checklist successfully conducted? An
observational study of social interactions in the oper…
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psnet.ahrq.gov/node/43142/psn-pdf
June 15, 2014 - Development and sustainability of an inpatient-to-
outpatient discharge handoff tool: a quality improvement
project.
June 15, 2014
Moy NY, Lee SJ, Chan T, et al. Development and sustainability of an inpatient-to-outpatient discharge
handoff tool: a quality improvement project. Jt Comm J Qual Patient Saf. 2014;40(5…
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psnet.ahrq.gov/node/46795/psn-pdf
March 28, 2018 - Systematic review and meta-analysis of the effectiveness
of pharmacist-led medication reconciliation in the
community after hospital discharge.
March 28, 2018
McNab D, Bowie P, Ross A, et al. Systematic review and meta-analysis of the effectiveness of pharmacist-
led medication reconciliation in the community afte…
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psnet.ahrq.gov/node/36052/psn-pdf
June 29, 2011 - Identifying risk factors for medical injury.
June 29, 2011
Guse CE, Yang H, Layde PM. Identifying risk factors for medical injury. Int J Qual Health Care.
2006;18(3):203-10.
https://psnet.ahrq.gov/issue/identifying-risk-factors-medical-injury
This cross-sectional study described associations between a medical inju…
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psnet.ahrq.gov/node/44234/psn-pdf
September 09, 2015 - Improving the reliability of verbal communication between
primary care physicians and pediatric hospitalists at
hospital discharge.
September 9, 2015
Mussman GM, Vossmeyer MT, Brady PW, et al. Improving the reliability of verbal communication between
primary care physicians and pediatric hospitalists at hospital d…
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psnet.ahrq.gov/node/44765/psn-pdf
November 23, 2016 - Communication relating to family members' involvement
and understandings about patients' medication
management in hospital.
November 23, 2016
Manias E. Communication relating to family members' involvement and understandings about patients'
medication management in hospital. Health Expect. 2015;18(5):850-66. doi:1…