-
psnet.ahrq.gov/node/850927/psn-pdf
June 21, 2023 - Room of horrors simulation in healthcare education: a
systematic review.
June 21, 2023
Lee SE, Repsha C, Seo WJ, et al. Room of horrors simulation in healthcare education: a systematic
review. Nurse Educ Today. 2023;126:105824. doi:10.1016/j.nedt.2023.105824.
https://psnet.ahrq.gov/issue/room-horrors-simulation-he…
-
psnet.ahrq.gov/node/43683/psn-pdf
April 22, 2015 - STOPP/START criteria for potentially inappropriate
prescribing in older people: version 2.
April 22, 2015
O'Mahony D, O'Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in
older people: version 2. Age Ageing. 2015;44(2):213-218. doi:10.1093/ageing/afu145.
https://psnet.ahr…
-
psnet.ahrq.gov/node/45272/psn-pdf
October 12, 2016 - Recognising and responding to 'cutting corners' when
providing nursing care: a qualitative study.
October 12, 2016
Jones A, Johnstone M-J, Duke M. Recognising and responding to 'cutting corners' when providing nursing
care: a qualitative study. J Clin Nurs. 2016;25(15-16):2126-33. doi:10.1111/jocn.13352.
https://p…
-
psnet.ahrq.gov/node/44860/psn-pdf
June 29, 2016 - Performance measures in neurosurgical patient care:
differing applications of patient safety indicators.
June 29, 2016
Moghavem N, McDonald KM, Ratliff JK, et al. Performance Measures in Neurosurgical Patient Care:
Differing Applications of Patient Safety Indicators. Med Care. 2016;54(4):359-64.
doi:10.1097/MLR.00…
-
psnet.ahrq.gov/node/850341/psn-pdf
June 14, 2023 - Impact of fatigue on anaesthesia providers: a scoping
review.
June 14, 2023
Scholliers A, Cornelis S, Tosi M, et al. Impact of fatigue on anaesthesia providers: a scoping review. Br J
Anaesth. 2023;130(5):622-635. doi:10.1016/j.bja.2022.12.011.
https://psnet.ahrq.gov/issue/impact-fatigue-anaesthesia-providers-scop…
-
psnet.ahrq.gov/node/40576/psn-pdf
July 06, 2011 - A prospective study of paediatric cardiac surgical
microsystems: assessing the relationships between non-
routine events, teamwork and patient outcomes.
July 6, 2011
Schraagen JM, Schouten T, Smit M, et al. A prospective study of paediatric cardiac surgical microsystems:
assessing the relationships between non-rou…
-
psnet.ahrq.gov/node/36021/psn-pdf
September 24, 2016 - Operational failures and interruptions in hospital nursing.
September 24, 2016
Tucker AL, Spear SJ. Operational failures and interruptions in hospital nursing. Health Serv Res. 2006;41(3
Pt 1):643-662.
https://psnet.ahrq.gov/issue/operational-failures-and-interruptions-hospital-nursing
This study discovered that n…
-
psnet.ahrq.gov/node/853058/psn-pdf
August 30, 2023 - Diagnostic reliability in teledermatology: a systematic
review and a meta-analysis.
August 30, 2023
Bourkas AN, Barone N, Bourkas MEC, et al. Diagnostic reliability in teledermatology: a systematic review
and a meta-analysis. BMJ Open. 2023;13(8):e068207. doi:10.1136/bmjopen-2022-068207.
https://psnet.ahrq.gov/iss…
-
psnet.ahrq.gov/node/837974/psn-pdf
August 31, 2022 - Fostering a just culture in healthcare organizations:
experiences in practice.
August 31, 2022
van Baarle E, Hartman L, Rooijakkers S, et al. Fostering a just culture in healthcare organizations:
experiences in practice. BMC Health Serv Res. 2022;22(1):1035. doi:10.1186/s12913-022-08418-z.
https://psnet.ahrq.gov/i…
-
psnet.ahrq.gov/node/43184/psn-pdf
May 14, 2014 - Often overlooked problems with handoffs: from the
intensive care unit to the operating room.
May 14, 2014
Evans AS, Yee M-S, Hogue CW. Often overlooked problems with handoffs: from the intensive care unit to
the operating room. Anesth Analg. 2014;118(3):687-9. doi:10.1213/ANE.0000000000000075.
https://psnet.ahrq.g…
-
psnet.ahrq.gov/node/42823/psn-pdf
December 18, 2013 - The Orthopaedic Error Index: development and
application of a novel national indicator for assessing the
relative safety of hospital care using a cross-sectional
approach.
December 18, 2013
Panesar SS, Netuveli G, Carson-Stevens A, et al. The orthopaedic error index: development and
application of a novel nationa…
-
psnet.ahrq.gov/node/50400/psn-pdf
October 02, 2019 - The role of personal health information management in
promoting patient safety in the home: a qualitative
analysis
October 2, 2019
Demiris G, Lin S-Y, Turner AM. The role of personal health information management in promoting patient
safety in the home: a qualitative analysis. Stud Health Technol Inform . 2019;264…
-
psnet.ahrq.gov/node/34674/psn-pdf
December 23, 2008 - Incidence and preventability of adverse drug events in
hospitalized patients.
December 23, 2008
Bates DW, Leape L, Petrycki S. Incidence and preventability of adverse drug events in hospitalized adults.
J Gen Intern Med. 1993;8(6):289-294.
https://psnet.ahrq.gov/issue/incidence-and-preventability-adverse-drug-even…
-
psnet.ahrq.gov/node/35017/psn-pdf
August 24, 2017 - The Field Guide to Human Error Investigations, Third
Edition.
August 24, 2017
Dekker S. Boca Baton, FL: CRC Press; 2017.
https://psnet.ahrq.gov/issue/field-guide-human-error-investigations-third-edition
This revised and reorganized book provides a primer on how human error causes mishaps and often
illustrates dee…
-
psnet.ahrq.gov/node/47459/psn-pdf
October 10, 2018 - People, processes, health IT and accurate patient
identification.
October 10, 2018
Quick Safety. October 1, 2018;(45):1-2.
https://psnet.ahrq.gov/issue/people-processes-health-it-and-accurate-patient-identification
This newsletter article reviews common problems related to patient identification and recommends
st…
-
psnet.ahrq.gov/node/72712/psn-pdf
February 03, 2021 - Not ‘just depression.’ She seemed trapped in a downward
mental health spiral. The real cause was a profound
shock.
February 3, 2021
Boodman SG. Washington Post. January 23, 2021.
https://psnet.ahrq.gov/issue/not-just-depression-she-seemed-trapped-downward-mental-health-spiral-real-
cause-was-profound
Misdia…
-
psnet.ahrq.gov/node/60842/psn-pdf
August 26, 2020 - Longitudinal medication reconciliation at hospital
admission, discharge and post-discharge.
August 26, 2020
Daliri S, Bouhnouf M, van de Meerendonk HWPC, et al. Longitudinal medication reconciliation at hospital
admission, discharge and post-discharge. Res Social Adm Pharm. 2020;17(4):677-684.
doi:10.1016/j.saphar…
-
psnet.ahrq.gov/node/44794/psn-pdf
May 21, 2019 - Medical Device Use Error: Root Cause Analysis.
May 21, 2019
Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790.
https://psnet.ahrq.gov/issue/medical-device-use-error-root-cause-analysis
Applying human factors engineering to examine mistakes associated with medical device use can lead …
-
psnet.ahrq.gov/node/42539/psn-pdf
September 27, 2016 - Causes of medication administration errors in hospitals: a
systematic review of quantitative and qualitative
evidence.
September 27, 2016
Keers RN, Williams SD, Cooke J, et al. Causes of medication administration errors in hospitals: a
systematic review of quantitative and qualitative evidence. Drug Saf. 2013;36(1…
-
psnet.ahrq.gov/node/34676/psn-pdf
December 23, 2008 - Driving improvement in patient care: lessons from
Toyota.
December 23, 2008
Thompson DN, Wolf GA, Spear SJ. Driving improvement in patient care: lessons from Toyota. J Nurs Adm.
2003;33(11):585-595.
https://psnet.ahrq.gov/issue/driving-improvement-patient-care-lessons-toyota
Representatives from University of Pit…