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psnet.ahrq.gov/node/844796/psn-pdf
September 18, 2019 - Workplace violence against anesthesiologists: we are not
immune to this patient safety threat.
September 18, 2019
Udoji MA, Ifeanyi-Pillette IC, Miller TR, Lin DM. Int Anesthesiol Clin. 2019;57:123-137.
https://psnet.ahrq.gov/issue/workplace-violence-against-anesthesiologists-we-are-not-immune-patient-
safety-thre…
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psnet.ahrq.gov/node/43579/psn-pdf
October 08, 2014 - Implications of Health Literacy for Public Health:
Workshop Summary.
October 8, 2014
Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health
Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/44893/psn-pdf
March 09, 2016 - Improving the governance of patient safety in emergency
care: a systematic review of interventions.
March 9, 2016
Hesselink G, Berben S, Beune T, et al. Improving the governance of patient safety in emergency care: a
systematic review of interventions. BMJ Open. 2016;6(1):e009837. doi:10.1136/bmjopen-2015-009837.
…
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psnet.ahrq.gov/node/45232/psn-pdf
August 10, 2016 - Promoting patient safety with perioperative hand-off
communication.
August 10, 2016
Robinson NL. Promoting Patient Safety With Perioperative Hand-off Communication. J Perianesth Nurs.
2016;31(3):245-53. doi:10.1016/j.jopan.2014.08.144.
https://psnet.ahrq.gov/issue/promoting-patient-safety-perioperative-hand-commun…
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psnet.ahrq.gov/node/852284/psn-pdf
August 09, 2023 - ‘Medical errors are the third leading cause of death’ and
other statistics you should question.
August 9, 2023
Jaklevic MC. HealthJournalism.org. July 27, 2023.
https://psnet.ahrq.gov/issue/medical-errors-are-third-leading-cause-death-and-other-statistics-you-should-
question
Published rates of medical errors con…
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psnet.ahrq.gov/node/837211/psn-pdf
May 25, 2022 - 4 actions to reduce medical errors in U.S. hospitals.
May 25, 2022
Toussaint JS, Segel KT. Harvard Business Review. April 20, 2022.
https://psnet.ahrq.gov/issue/4-actions-reduce-medical-errors-us-hospitals
The patient safety movement has had mixed results in sustaining improvement and commitment. This
comment…
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psnet.ahrq.gov/node/852278/psn-pdf
August 09, 2023 - Identifying failure modes in telemedicine: an instructional
needs assessment.
August 9, 2023
Monkman H, Kuziemsky C, Homco J, et al. Identifying failure modes in telemedicine: an instructional needs
assessment. Stud Health Technol Inform. 2023;304:39-43. doi:10.3233/shti230365.
https://psnet.ahrq.gov/issue/identif…
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psnet.ahrq.gov/node/38977/psn-pdf
September 30, 2009 - Enhanced end-of-life care associated with deploying a
rapid response team: a pilot study.
September 30, 2009
Vazquez R, Gheorghe C, Grigoriyan A, et al. Enhanced end-of-life care associated with deploying a rapid
response team: a pilot study. J Hosp Med. 2009;4(7):449-52. doi:10.1002/jhm.451.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/72552/psn-pdf
December 09, 2020 - Hospital-acquired SARS-CoV-2 infection: lessons for
public health.
December 9, 2020
Richterman A, Meyerowitz EA, Cevik M. Hospital-acquired SARS-CoV-2 infection: lessons for public
health. JAMA. 2020;324(21):2155. doi:10.1001/jama.2020.21399.
https://psnet.ahrq.gov/issue/hospital-acquired-sars-cov-2-infection-less…
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psnet.ahrq.gov/node/44032/psn-pdf
April 01, 2015 - ACOG Committee Opinion #621: patient safety and health
information technology.
April 1, 2015
Improvement C on PS and Q, Management C on P. Committee opinion no. 621: Patient safety and health
information technology. Obstet Gynecol. 2015;125(1):282-3. doi:10.1097/01.AOG.0000459867.14114.7a.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/44204/psn-pdf
June 17, 2015 - Effectiveness of interventions to improve patient
handover in surgery: a systematic review.
June 17, 2015
Pucher PH, Johnston MJ, Aggarwal R, et al. Effectiveness of interventions to improve patient handover in
surgery: A systematic review. Surgery. 2015;158(1):85-95. doi:10.1016/j.surg.2015.02.017.
https://psnet.…
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psnet.ahrq.gov/node/47055/psn-pdf
May 23, 2018 - Surgical checklists save lives—but once in a while, they
don't. Why?
May 23, 2018
Mukherjee S. New York Times Magazine. May 9, 2018.
https://psnet.ahrq.gov/issue/surgical-checklists-save-lives-once-while-they-dont-why
Checklists can coordinate action and communication to augment safety, but human and system factor…
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psnet.ahrq.gov/node/39275/psn-pdf
February 03, 2010 - Medical librarians supporting information systems project
lifecycles toward improved patient safety.
February 3, 2010
Saimbert MK, Zhang Y, Pierce J, et al. Medical librarians supporting information systems project lifecycles
toward improved patient safety. Medical librarians possess expertise to navigate various s…
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psnet.ahrq.gov/node/60020/psn-pdf
March 04, 2020 - The eNOTSS platform for surgeons’ nontechnical skills
performance improvement.
March 4, 2020
Pradarelli JC, Yule S, Smink DS. The eNOTSS Platform for Surgeons’ Nontechnical Skills Performance
Improvement. JAMA Surg. 2020;155(5):438-439. doi:10.1001/jamasurg.2019.5880.
https://psnet.ahrq.gov/issue/enotss-platform-s…
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psnet.ahrq.gov/node/44046/psn-pdf
August 21, 2015 - Development of an instrument to measure the unintended
consequences of EHRs.
August 21, 2015
Carrington JM, Gephart SM, Verran JA, et al. Development of an Instrument to Measure the Unintended
Consequences of EHRs. West J Nurs Res. 2015;37(7):842-58. doi:10.1177/0193945915576083.
https://psnet.ahrq.gov/issue/devel…
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psnet.ahrq.gov/node/41718/psn-pdf
October 03, 2012 - Duty hours, quality of care, and patient safety: general
surgery resident perceptions.
October 3, 2012
Borman KR, Jones AT, Shea JA. Duty hours, quality of care, and patient safety: general surgery resident
perceptions. J Am Coll Surg. 2012;215(1):70-7; discussion 77-9. doi:10.1016/j.jamcollsurg.2012.02.010.
https…
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psnet.ahrq.gov/node/39517/psn-pdf
May 25, 2010 - A prospective controlled trial of the effect of a multi-
faceted intervention on early recognition and intervention
in deteriorating hospital patients.
May 25, 2010
Mitchell IA, McKay H, Van Leuvan C, et al. A prospective controlled trial of the effect of a multi-faceted
intervention on early recognition and inter…
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psnet.ahrq.gov/node/866285/psn-pdf
October 30, 2023 - Executive Order on the Safe, Secure, and Trustworthy
Development and Use of Artificial Intelligence.
October 30, 2023
Washington DC: The White House; October 30, 2023. EO 14110.
https://psnet.ahrq.gov/issue/executive-order-safe-secure-and-trustworthy-development-and-use-artificial-
intelligence
Artificial in…
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psnet.ahrq.gov/node/35182/psn-pdf
April 11, 2011 - Standard drug concentrations and smart-pump
technology reduce continuous-medication-infusion errors
in pediatric patients.
April 11, 2011
Larsen G, Parker HB, Cash J, et al. Standard drug concentrations and smart-pump technology reduce
continuous-medication-infusion errors in pediatric patients. Pediatrics. 2005;1…
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psnet.ahrq.gov/node/46650/psn-pdf
July 12, 2018 - Towards a more patient-centered approach to medication
safety.
July 12, 2018
Lee JL, Dy SM, Gurses AP, et al. Towards a More Patient-Centered Approach to Medication Safety. J
Patient Exp. 2018;5(2):83-87. doi:10.1177/2374373517727532.
https://psnet.ahrq.gov/issue/towards-more-patient-centered-approach-medication-s…