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psnet.ahrq.gov/node/43216/psn-pdf
June 25, 2014 - Banning the handshake from the health care setting.
June 25, 2014
Sklansky M, Nadkarni N, Ramirez-Avila L. Banning the handshake from the health care setting. JAMA.
2014;311(24):2477-8.
https://psnet.ahrq.gov/issue/banning-handshake-health-care-setting
Hand hygiene is an important practice that prevents transmissi…
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psnet.ahrq.gov/node/45084/psn-pdf
April 27, 2016 - Nurses say stress interferes with caring for their patients.
April 27, 2016
Yu A. Health Shots. National Public Radio. April 15, 2016.
https://psnet.ahrq.gov/issue/nurses-say-stress-interferes-caring-their-patients
Many health care professionals exhibit symptoms of burnout, which may impair their ability to maintai…
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psnet.ahrq.gov/node/42195/psn-pdf
October 08, 2013 - Medication errors in the management of anaphylaxis in a
pediatric emergency department.
October 8, 2013
Benkelfat R, Gouin S, Larose G, et al. Medication errors in the management of anaphylaxis in a pediatric
emergency department. J Emerg Med. 2013;45(3):419-425. doi:10.1016/j.jemermed.2012.11.069.
https://psnet.a…
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psnet.ahrq.gov/node/42826/psn-pdf
December 18, 2013 - Improvement of medication event interventions through
use of an electronic database.
December 18, 2013
Merandi J, Morvay S, Lewe D, et al. Improvement of medication event interventions through use of an
electronic database. Am J Health Syst Pharm. 2013;70(19):1708-14. doi:10.2146/ajhp130021.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/42906/psn-pdf
February 27, 2014 - From heroism to safe design: leveraging technology.
February 27, 2014
Pronovost P, Bo-Linn GW, Sapirstein A. From heroism to safe design: leveraging technology.
Anesthesiology. 2014;120(3):526-9. doi:10.1097/ALN.0000000000000127.
https://psnet.ahrq.gov/issue/heroism-safe-design-leveraging-technology
This commentar…
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psnet.ahrq.gov/node/36542/psn-pdf
August 06, 2008 - Pediatric rapid response teams in the academic medical
center.
August 6, 2008
Mistry KP, Turi J, Hueckel RM, et al. Pediatric Rapid Response Teams in the Academic Medical Center.
Clin Pediatr Emerg Med. 2006;7(4). doi:10.1016/j.cpem.2006.08.010.
https://psnet.ahrq.gov/issue/pediatric-rapid-response-teams-academic-…
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psnet.ahrq.gov/node/37558/psn-pdf
July 05, 2013 - Patient safety and quality improvement.
July 5, 2013
Agency for Healthcare Research and Quality. Fed Register. February 12, 2008;73(29):8112-8183.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement
These proposed rules seek to support the implementation of portions of the Patient Safety and Quality…
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psnet.ahrq.gov/node/41728/psn-pdf
January 18, 2013 - Who's covering our loved ones: surprising barriers in the
sign-out process.
January 18, 2013
Antonoff MB, Berdan EA, Kirchner VA, et al. Who's covering our loved ones: surprising barriers in the sign-
out process. Am J Surg. 2013;205(1):77-84. doi:10.1016/j.amjsurg.2012.05.009.
https://psnet.ahrq.gov/issue/whos-co…
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psnet.ahrq.gov/node/39344/psn-pdf
March 03, 2010 - Mistake-proofing healthcare: why stopping processes
may be a good start.
March 3, 2010
Grout JR, Toussaint JS. Mistake-proofing healthcare: Why stopping processes may be a good start. Bus
Horiz. 2009;53(2):149-156. doi:10.1016/j.bushor.2009.10.007.
https://psnet.ahrq.gov/issue/mistake-proofing-healthcare-why-stopp…
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psnet.ahrq.gov/node/50771/psn-pdf
May 29, 2024 - AHRQ Health Literacy Universal Precautions Toolkit. 3rd
edition.
May 29, 2024
Brach C, ed. Rockville, MD: Agency for Healthcare Research and Quality; March 2024. AHRQ Publication
No. 15-0023-EF.
https://psnet.ahrq.gov/issue/ahrq-health-literacy-universal-precautions-toolkit-2nd-edition
The AHRQ Health Literacy Un…
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psnet.ahrq.gov/node/34880/psn-pdf
April 04, 2005 - Cedars-Sinai doctors cling to pen and paper: transition to
electronic medical records proves difficult.
April 4, 2005
Connolly C. Washington Post. March 21, 2005
https://psnet.ahrq.gov/issue/cedars-sinai-doctors-cling-pen-and-paper-transition-electronic-medical-
records-proves
A high-profile misstep in implementi…
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psnet.ahrq.gov/training-catalog/capture-falls-collaboration-and-proactive-teamwork-used-reduce-falls-program
August 11, 2025 - CAPTURE Falls (Collaboration And Proactive Teamwork Used to Reduce Falls) Program
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Organization:
Organization
University of Nebraska College of…
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psnet.ahrq.gov/node/36688/psn-pdf
May 27, 2011 - Prevention of potential errors in resuscitation
medications orders by means of a computerised
physician order entry in paediatric critical care.
May 27, 2011
Vardi A; Efrati O; Levin I; Matok I; Rubinstein M; Paret G; Barzilay Z.
https://psnet.ahrq.gov/issue/prevention-potential-errors-resuscitation-medications-or…
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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/42904/psn-pdf
February 11, 2025 - Safety Assurance Factors for EHR Resilience: SAFER
Guides.
February 11, 2025
Washington, DC: Assistant Secretary for Technology Policy.
https://psnet.ahrq.gov/issue/safety-assurance-factors-ehr-resilience-safer-guides
Health information technologies are seen to both contribute to and detract from health care safet…
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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/46055/psn-pdf
July 26, 2017 - Bridging the gap between work-as-imagined and work-as-
done.
July 26, 2017
Deutsch ES. PA-PSRS Patient Saf Advis. June 2017;14:80-83.
https://psnet.ahrq.gov/issue/bridging-gap-between-work-imagined-and-work-done
Understanding what is possible in the context of frontline practice is key when designing enhancements …
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psnet.ahrq.gov/node/46553/psn-pdf
October 25, 2017 - Telehealth.
October 25, 2017
Tuckson R, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med. 2017;377(16):1585-1592.
doi:10.1056/NEJMsr1503323.
https://psnet.ahrq.gov/issue/telehealth
Telemedicine can improve patient experience and access to health care. This commentary reviews the
current state of telehealth practi…
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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/73326/psn-pdf
June 01, 2021 - CANDOR Webinar Series.
June 1, 2021
Patient Safety Movement Foundation. 2021.
https://psnet.ahrq.gov/issue/candor-webinar-series
The Communication and Optimal Resolution (CANDOR) model was designed to support early error
disclosure with patients and families after mistakes in care occur. This three-part webi…