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psnet.ahrq.gov/node/35540/psn-pdf
August 05, 2009 - Lost in translation: challenges and opportunities in
physician-to-physician communication during patient
handoffs.
August 5, 2009
Solet DJ, Norvell M, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-
physician communication during patient handoffs. Acad Med. 2005;80(12):1094-9.
…
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psnet.ahrq.gov/node/45365/psn-pdf
August 03, 2016 - Workarounds and test results follow-up in electronic
health record–based primary care.
August 3, 2016
Menon S, Murphy DR, Singh H, et al. Workarounds and Test Results Follow-up in Electronic Health
Record-Based Primary Care. Appl Clin Inform. 2016;7(2):543-559. doi:10.4338/ACI-2015-10-RA-0135.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/860722/psn-pdf
January 17, 2024 - Ten years of incident reports on in-hospital cardiac arrest
- Are they useful for improvements?
January 17, 2024
Djärv T. Ten years of incident reports on in-hospital cardiac arrest – Are they useful for improvements?
Resusc Plus. 2023;17:100525. doi:10.1016/j.resplu.2023.100525.
https://psnet.ahrq.gov/issue/ten-y…
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psnet.ahrq.gov/node/838321/psn-pdf
October 12, 2022 - Meeting the Moment: Addressing Barriers and Facilitating
Clinical Adoption of Artificial Intelligence in Medical
Diagnosis.
October 12, 2022
Adler-Milstein J, Aggarwal N, Ahmed M, et al. NAM Perspectives. Washington DC: National Academy of
Medicine; 2022.
https://psnet.ahrq.gov/issue/meeting-moment-addressing-bar…
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psnet.ahrq.gov/node/46765/psn-pdf
April 04, 2018 - Advancing perinatal patient safety through application of
safety science principles using health IT.
April 4, 2018
Webb J, Sorensen A, Sommerness SA, et al. Advancing perinatal patient safety through application of
safety science principles using health IT. BMC Med Inform Decis Mak. 2017;17(1):176.
doi:10.1186/s12…
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psnet.ahrq.gov/node/47374/psn-pdf
April 07, 2019 - Developing a conceptual framework for patient safety
culture in emergency department: a review of the
literature.
April 7, 2019
Alshyyab MA, FitzGerald G, Dingle K, et al. Developing a conceptual framework for patient safety culture in
emergency department: A review of the literature. Int J Health Plann Manage. 20…
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psnet.ahrq.gov/node/45851/psn-pdf
February 22, 2017 - Eight years of decreased methicillin-resistant
Staphylococcus aureus health care–associated infections
associated with a Veterans Affairs prevention initiative.
February 22, 2017
Evans ME, Kralovic SM, Simbartl LA, et al. Eight years of decreased methicillin-resistant Staphylococcus
aureus health care-associated i…
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psnet.ahrq.gov/node/72657/psn-pdf
January 20, 2021 - Establishing a multi-institutional quality and patient
safety consortium: collaboration across affiliates in a
community-based medical school.
January 20, 2021
Hillman E, Paul J, Neustadt M, et al. Establishing a multi-institutional quality and patient safety consortium:
collaboration across affiliates in a commun…
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psnet.ahrq.gov/node/44507/psn-pdf
July 18, 2016 - Six habits to enhance MET performance under stress: a
discussion paper reviewing team mechanisms for
improved patient outcomes.
July 18, 2016
Fein EC, Mackie B, Chernyak-Hai L, et al. Six habits to enhance MET performance under stress: A
discussion paper reviewing team mechanisms for improved patient outcomes. Aus…
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psnet.ahrq.gov/node/47554/psn-pdf
November 07, 2018 - Diagnostic Excellence Initiative.
November 7, 2018
Gordon and Betty Moore Foundation.
https://psnet.ahrq.gov/issue/diagnostic-excellence-improving-experience-and-outcomes-patient-care
Missed or delayed diagnoses lead to delays in care and significant preventable harm for patients. Despite
an increasing focus on di…
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psnet.ahrq.gov/node/45876/psn-pdf
January 01, 2021 - Making residents part of the safety culture: improving
error reporting and reducing harms.
February 15, 2017
Fox MD, Bump GM, Butler GA, et al. Making Residents Part of the Safety Culture: Improving Error
Reporting and Reducing Harms. J Patient Saf. 2021;17(5):e373-e378.
doi:10.1097/PTS.0000000000000344.
https://…
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psnet.ahrq.gov/node/47910/psn-pdf
August 21, 2019 - Cognitive Informatics: Reengineering Clinical Workflow
for Safer and More Efficient Care.
August 21, 2019
Zheng K, Westbrook J, Kannampallil TG, Patel VL, eds. Springer International Publishing; 2019. ISBN:
9783030169152.
https://psnet.ahrq.gov/issue/cognitive-informatics-reengineering-clinical-workflow-safer-and-…
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psnet.ahrq.gov/node/837631/psn-pdf
July 06, 2022 - The impact of an electronic alert to reduce the risk of co-
prescription of low molecular weight heparins and direct
oral anticoagulants.
July 6, 2022
Brown A, Cavell G, Dogra N, et al. The impact of an electronic alert to reduce the risk of co-prescription of
low molecular weight heparins and direct oral anticoag…
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psnet.ahrq.gov/node/45510/psn-pdf
October 19, 2016 - How to perform a root cause analysis for workup and
future prevention of medical errors: a review.
October 19, 2016
Charles R, Hood B, DeRosier JM, et al. How to perform a root cause analysis for workup and future
prevention of medical errors: a review. Patient Saf Surg. 2016;10:20. doi:10.1186/s13037-016-0107-8.
…
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psnet.ahrq.gov/node/45605/psn-pdf
November 30, 2016 - Advancing interprofessional patient safety education for
medical, nursing, and pharmacy learners during clinical
rotations.
November 30, 2016
Thom KA, Heil EL, Croft LD, et al. Advancing interprofessional patient safety education for medical,
nursing, and pharmacy learners during clinical rotations. J Interprof Ca…
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psnet.ahrq.gov/node/845348/psn-pdf
February 02, 2012 - Liquid-based Papanicolaou tests in endometrial
carcinoma diagnosis: performance, error root cause
analysis, and quality improvement.
February 2, 2012
Sams SB, Currens HS, Raab SS. Liquid-based Papanicolaou tests in endometrial carcinoma diagnosis:
performance, error root cause analysis, and quality improvement. Am…
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psnet.ahrq.gov/node/866596/psn-pdf
August 28, 2024 - Electronic Test Result Communication in the Era of the
21st Century Cures Act
August 28, 2024
Bradford A, Ehsan S, Shahid U, et al. Electronic Test Result Communication In The Era Of The 21St
Century Cures Act. Rockville, MD: Agency for Healthcare Research and Quality; July 2024. AHRQ
Publication No. 24-0010-3-EF
…
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psnet.ahrq.gov/node/72574/psn-pdf
December 16, 2020 - Transitions from one electronic health record to another:
challenges, pitfalls, and recommendations.
December 16, 2020
Huang C, Koppel R, McGreevey JD, et al. Transitions from one electronic health record to another:
challenges, pitfalls, and recommendations. Appl Clin Inform. 2020;11(05):742-754. doi:10.1055/s-004…
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psnet.ahrq.gov/node/73632/psn-pdf
January 01, 2022 - I-PSI: short- and long-term efficacy of a comprehensive
initiative to promote patient safety event reporting by
trainees.
August 25, 2021
Prabhu V, Mikhly M, Chung R, et al. I-PSI: short- and long-term efficacy of a comprehensive initiative to
promote patient safety event reporting by trainees. Am J Med Qual. 2022…
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psnet.ahrq.gov/node/836919/psn-pdf
April 13, 2022 - Psychological intervention to improve communication
and patient safety in obstetrics: examination of the health
action process approach.
April 13, 2022
Derksen C, Kötting L, Keller FM, et al. Psychological intervention to improve communication and patient
safety in obstetrics: examination of the health action proc…