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psnet.ahrq.gov/node/73425/psn-pdf
June 23, 2021 - A qualitative study of what care workers do to provide
patient safety at home through telecare.
June 23, 2021
Stokke R, Melby L, Isaksen J, et al. A qualitative study of what care workers do to provide patient safety at
home through telecare. BMC Health Serv Res. 2021;21(1):553. doi:10.1186/s12913-021-06556-4.
htt…
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psnet.ahrq.gov/node/836955/psn-pdf
April 20, 2022 - The National Imperative to Improve Nursing Home
Quality: Honoring Our Commitment to Residents,
Families, and Staff.
April 20, 2022
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies
Press; 2022. ISBN: 9780309686259
https://psnet.ahrq.gov/issue/national-imperative-imp…
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psnet.ahrq.gov/node/838243/psn-pdf
October 05, 2022 - Evaluation of medication incidents in a long-term care
facility using electronic medication administration
records and barcode technology.
October 5, 2022
Fuller AEC, Guirguis LM, Sadowski CA, et al. Evaluation of medication incidents in a long-term care facility
using electronic medication administration records …
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psnet.ahrq.gov/node/851453/psn-pdf
July 19, 2023 - Association of polypharmacy and potential drug-drug
interactions with adverse treatment outcomes in older
adults with advanced cancer.
July 19, 2023
Mohamed MR, Mohile SG, Juba KM, et al. Association of polypharmacy and potential drug?drug
interactions with adverse treatment outcomes in older adults with advanced …
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psnet.ahrq.gov/node/854987/psn-pdf
January 01, 2024 - Frequency, type, and degree of potential harm of adverse
safety events among pediatric emergency medical
services encounters.
November 1, 2023
Cicero MX, Baird J, Brown L, et al. Frequency, type, and degree of potential harm of adverse safety events
among pediatric emergency medical services encounters. Prehosp Em…
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psnet.ahrq.gov/node/846707/psn-pdf
March 29, 2023 - Effect of patient safety education interventions on patient
safety culture of health care professionals: systematic
review and meta-analysis.
March 29, 2023
Agbar F, Zhang S, Wu Y, et al. Effect of patient safety education interventions on patient safety culture of
health care professionals: Systematic review and …
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psnet.ahrq.gov/node/47007/psn-pdf
May 02, 2018 - Workarounds to intended use of health information
technology: a narrative review of the human factors
engineering literature.
May 2, 2018
Patterson ES. Workarounds to Intended Use of Health Information Technology: A Narrative Review of the
Human Factors Engineering Literature. Hum Factors. 2018;60(3):281-292.
doi…
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psnet.ahrq.gov/node/865817/psn-pdf
May 08, 2024 - Using Healthcare Failure Mode and Effect Analysis in
prospective medication safety risk management in
secondary care inpatient wards.
May 8, 2024
Sova PM, Holmström A-R, Airaksinen M, et al. Using Healthcare Failure Mode and Effect Analysis in
prospective medication safety risk management in secondary care inpatie…
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psnet.ahrq.gov/node/45631/psn-pdf
July 02, 2017 - Implementation science: a neglected opportunity to
accelerate improvements in the safety and quality of
surgical care.
July 2, 2017
Hull L, Athanasiou T, Russ S. Implementation Science: A Neglected Opportunity to Accelerate
Improvements in the Safety and Quality of Surgical Care. Ann Surg. 2017;265(6):1104-1112.
…
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psnet.ahrq.gov/node/42724/psn-pdf
December 06, 2013 - Adverse drug events after hospital discharge in older
adults: types, severity, and involvement of Beers criteria
medications.
December 6, 2013
Kanaan AO, Donovan JL, Duchin NP, et al. Adverse drug events after hospital discharge in older adults:
types, severity, and involvement of Beers Criteria Medications. J Am …
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psnet.ahrq.gov/node/838186/psn-pdf
September 28, 2022 - Understanding teamwork in rapidly deployed
interprofessional teams in intensive and acute care: a
systematic review of reviews.
September 28, 2022
Schilling S, Armaou M, Morrison Z, et al. Understanding teamwork in rapidly deployed interprofessional
teams in intensive and acute care: a systematic review of reviews…
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psnet.ahrq.gov/node/73350/psn-pdf
June 02, 2021 - Learning during crisis: the impact of COVID-19 on
hospital-acquired pressure injury incidence.
June 2, 2021
Polancich S, Hall AG, Miltner RS, et al. Learning during crisis: the impact of COVID-19 on hospital-acquired
pressure injury incidence. J Healthc Qual. 2021;43(3):137-144. doi:10.1097/jhq.0000000000000301.
h…
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psnet.ahrq.gov/node/841152/psn-pdf
December 07, 2022 - Interprofessional clinical event debriefing-does it make a
difference? Attitudes of emergency department care
providers to INFO clinical event debriefings.
December 7, 2022
Rose SC, Ashari NA, Davies JM, et al. Interprofessional clinical event debriefing-does it make a difference?
Attitudes of emergency department…
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psnet.ahrq.gov/node/866242/psn-pdf
July 10, 2024 - Evaluating the prevalence of four recommended practices
for suicide prevention following hospital discharge.
July 10, 2024
Chitavi SO, Patrianakos J, Williams SC, et al. Evaluating the prevalence of four recommended practices for
suicide prevention following hospital discharge. Jt Comm J Qual Patient Saf. 2024;50(6…
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psnet.ahrq.gov/node/860390/psn-pdf
January 10, 2024 - Key factors for effective implementation of healthcare
workers support interventions after patient safety
incidents in health organisations: a scoping review.
January 10, 2024
Guerra-Paiva S, Lobão MJ, Simões DG, et al. Key factors for effective implementation of healthcare
workers support interventions after pati…
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psnet.ahrq.gov/node/867445/psn-pdf
January 08, 2025 - Using human factors methods to mitigate bias in artificial
intelligence-based clinical decision support.
January 8, 2025
Militello LG, Diiulio J, Wilson DL, et al. Using human factors methods to mitigate bias in artificial
intelligence-based clinical decision support. J Am Med Inform Assoc. 2025;32(2):398-403.
doi…
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psnet.ahrq.gov/node/867440/psn-pdf
January 08, 2025 - How can specialist investigation agencies inform system-
wide learning for patient safety? A qualitative study of
perspectives on the early years of the English Healthcare
Safety Investigation Branch.
January 8, 2025
Crompton A, Waring J, Macrae C, et al. How can specialist investigation agencies inform system-wid…
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psnet.ahrq.gov/node/867594/psn-pdf
January 22, 2025 - A systematic review on the evidence of misdiagnosis in
dementia and its impact on accessing dementia care.
January 22, 2025
Giebel C, Silva?Ribeiro W, Watson J, et al. A systematic review on the evidence of misdiagnosis in
dementia and its impact on accessing dementia care. Int J Geriat Psychiatry. 2024;39(10):e615…
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psnet.ahrq.gov/node/866167/psn-pdf
June 19, 2024 - Risk factors associated with medication administration
errors in children: a prospective direct observational
study of paediatric inpatients.
June 19, 2024
Westbrook JI, Li L, Woods AL, et al. Risk factors associated with medication administration errors in
children: a prospective direct observational study of pae…
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psnet.ahrq.gov/node/61112/psn-pdf
November 11, 2020 - Repurposing clinical decision support system data to
measure dosing errors and clinician-level quality of care.
November 11, 2020
Chin DL, Wilson MH, Trask AS, et al. Repurposing clinical decision support system data to measure dosing
errors and clinician-level quality of care. J Med Syst. 2020;44(10):185. doi:10.1…