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psnet.ahrq.gov/node/47030/psn-pdf
June 06, 2018 - Creating a safer operating room: groups, team dynamics
and crew resource management principles.
June 6, 2018
Wakeman D, Langham MR. Creating a safer operating room: Groups, team dynamics and crew resource
management principles. Semin Pediatr Surg. 2018;27(2):107-113. doi:10.1053/j.sempedsurg.2018.02.008.
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psnet.ahrq.gov/node/35361/psn-pdf
July 16, 2009 - Improving Patient Safety Through Informed Consent for
Patients with Limited Health Literacy.
July 16, 2009
Wu HW, Nishimi RY, Page-Lopez CM, et al. Washington DC: National Quality Forum; 2005.
https://psnet.ahrq.gov/issue/improving-patient-safety-through-informed-consent-patients-limited-health-
literacy
In the 2…
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psnet.ahrq.gov/node/47864/psn-pdf
April 08, 2019 - Healthcare scandals and the failings of doctors: do
official inquiries hold the profession to account?
April 8, 2019
Mannion R, Davies H, Powell M, et al. Healthcare scandals and the failings of doctors. J Health Organ
Manag. 2019;33(2):221-240. doi:10.1108/JHOM-04-2018-0126.
https://psnet.ahrq.gov/issue/healthcar…
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psnet.ahrq.gov/node/74078/psn-pdf
November 17, 2021 - Safety learning among young newly employed workers in
three sectors: a challenge to the assumed order of things.
November 17, 2021
Grytnes R, Nielsen ML, Jørgensen A, et al. Safety learning among young newly employed workers in three
sectors: a challenge to the assumed order of things. Safety Sci. 2021;143:105417.
…
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psnet.ahrq.gov/node/39645/psn-pdf
August 03, 2010 - Monitoring and reducing central line-associated
bloodstream infections: a national survey of state
hospital associations.
August 3, 2010
Murphy DJ, Needham DM, Goeschel CA, et al. Monitoring and reducing central line-associated
bloodstream infections: a national survey of state hospital associations. Am J Med Qual…
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psnet.ahrq.gov/node/44726/psn-pdf
January 07, 2016 - The impact of resident duty hour and supervision
changes: a review.
January 7, 2016
Greenberg WE, Borus JF. The Impact of Resident Duty Hour and Supervision Changes: A Review. Harv
Rev Psychiatry. 2016;24(1):69-76. doi:10.1097/HRP.0000000000000061.
https://psnet.ahrq.gov/issue/impact-resident-duty-hour-and-supervi…
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psnet.ahrq.gov/node/47783/psn-pdf
April 10, 2019 - An IDEA: safety training to improve critical thinking by
individuals and teams.
April 10, 2019
Browne AM, Deutsch ES, Corwin K, et al. An IDEA: Safety Training to Improve Critical Thinking by
Individuals and Teams. Am J Med Qual. 2019;34(6):569-576. doi:10.1177/1062860618820687.
https://psnet.ahrq.gov/issue/idea-s…
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psnet.ahrq.gov/node/45643/psn-pdf
November 30, 2016 - Sources and magnitude of error in preparing morphine
infusions for nurse–patient controlled analgesia in a UK
paediatric hospital.
November 30, 2016
Rashed AN, Tomlin S, Aguado V, et al. Sources and magnitude of error in preparing morphine infusions for
nurse-patient controlled analgesia in a UK paediatric hospita…
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psnet.ahrq.gov/node/46844/psn-pdf
March 07, 2018 - Learning collaboratives: insights and a new taxonomy
from AHRQ's two decades of experience.
March 7, 2018
Nix M, McNamara P, Genevro J, et al. Learning Collaboratives: Insights And A New Taxonomy From
AHRQ's Two Decades Of Experience. Health Aff (Millwood). 2018;37(2):205-212.
doi:10.1377/hlthaff.2017.1144.
https…
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psnet.ahrq.gov/node/838183/psn-pdf
September 28, 2022 - Adding automation and independent dual verification to
reduce wrong blood in tube (WBIT) events.
September 28, 2022
Passwater M, Huggins YM, Delvo Favre ED, et al. Adding automation and independent dual verification to
reduce wrong blood in tube (WBIT) events. Am J Clin Pathol. 2022;158(2):212-215.
doi:10.1093/ajc…
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psnet.ahrq.gov/node/838310/psn-pdf
October 12, 2022 - Intravenous smart pumps at the point of care: a
descriptive, observational study.
October 12, 2022
Giuliano KK, Blake JWC, Bittner NP, et al. Intravenous smart pumps at the point of care: a descriptive,
observational study. J Patient Saf. 2022;18(6):553-558. doi:10.1097/pts.0000000000001057.
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psnet.ahrq.gov/node/45783/psn-pdf
March 25, 2017 - Year-end resident clinic handoffs: narrative review and
recommendations for improvement.
March 25, 2017
Pincavage A, Donnelly MJ, Young JQ, et al. Year-End Resident Clinic Handoffs: Narrative Review and
Recommendations for Improvement. Jt Comm J Qual Patient Saf. 2017;43(2):71-79.
doi:10.1016/j.jcjq.2016.11.006.
…
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psnet.ahrq.gov/node/47541/psn-pdf
March 04, 2019 - Health outcomes of deprescribing interventions among
older residents in nursing homes: a systematic review
and meta-analysis.
March 4, 2019
Kua C-H, Mak VSL, Lee SWH. Health Outcomes of Deprescribing Interventions Among Older Residents in
Nursing Homes: A Systematic Review and Meta-analysis. J Amer Med Direct Asso…
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psnet.ahrq.gov/node/46793/psn-pdf
February 28, 2018 - Patient safety movement: history and future directions.
February 28, 2018
Lark ME, Kirkpatrick K, Chung KC. Patient Safety Movement: History and Future Directions. J Hand Surg
Am. 2018;43(2). doi:10.1016/j.jhsa.2017.11.006.
https://psnet.ahrq.gov/issue/patient-safety-movement-history-and-future-directions
The pati…
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psnet.ahrq.gov/node/73565/psn-pdf
August 04, 2021 - Healthcare worker serious safety events: applying
concepts from patient safety to improve healthcare
worker safety.
August 4, 2021
Foster C, Doud L, Palangyo T, et al. Healthcare worker serious safety events: applying concepts from
patient safety to improve healthcare worker safety. Pediatr Qual Saf. 2021;6(4):e43…
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psnet.ahrq.gov/node/44681/psn-pdf
April 13, 2016 - Triggers, bundles, protocols, and checklists—what every
maternal care provider needs to know.
April 13, 2016
Arora KS, Shields LE, Grobman WA, et al. Triggers, bundles, protocols, and checklists--what every
maternal care provider needs to know. Am J Obstet Gynecol. 2016;214(4):444-451.
doi:10.1016/j.ajog.2015.10.0…
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psnet.ahrq.gov/node/72785/psn-pdf
July 22, 2024 - Using Innovative Digital Healthcare Solutions to Improve
Quality at the Point of Care (R21/R33 - Clinical Trial
Optional).
July 22, 2024
Rockville, MD: Agency for Healthcare Research and Quality; July 19, 2024. PA-24-266.
https://psnet.ahrq.gov/issue/using-innovative-digital-healthcare-solutions-improve-qual…
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psnet.ahrq.gov/node/852451/psn-pdf
August 16, 2023 - The impact of transition to a digital hospital on
medication errors (TIME study).
August 16, 2023
Engstrom T, McCourt E, Canning M, et al. The impact of transition to a digital hospital on medication errors
(TIME study). NPJ Digit Med. 2023;6(1):133. doi:10.1038/s41746-023-00877-w.
https://psnet.ahrq.gov/issue/imp…
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psnet.ahrq.gov/node/50555/psn-pdf
October 16, 2019 - Improving critical incident reporting in primary care
through education and involvement.
October 16, 2019
Müller BS, Beyer M, Blazejewski T, et al. Improving critical incident reporting in primary care through
education and involvement. BMJ Open Qual. 2019;8(3):e000556. doi:10.1136/bmjoq-2018-000556.
https://psnet…
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psnet.ahrq.gov/node/73353/psn-pdf
June 02, 2021 - Enhancing high alert medication knowledge among
pharmacy, nursing, and medical staff.
June 2, 2021
Sullivan KM, Le PL, Ditoro MJ, et al. Enhancing high alert medication knowledge among pharmacy,
nursing, and medical staff. J Patient Saf. 2021;17(4):311-315. doi:10.1097/pts.0b013e3182878113.
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