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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38704/psn-pdf
    July 31, 2012 - Clinical Handover: Critical Communications. July 31, 2012 Med J Aust. 2009;190(s11):s108-s157. https://psnet.ahrq.gov/issue/clinical-handover-critical-communications This supplement discusses Australian efforts to improve handover safety with emphasis on flexible standardization, communication improvement, and inf…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36399/psn-pdf
    May 04, 2015 - Tips for Safer Surgery. May 4, 2015 Surgical Care Improvement Project. Oklahoma City, OK: Oklahoma Foundation for Medical Quality; 2006. https://psnet.ahrq.gov/issue/tips-safer-surgery This tip sheet provides a list of questions consumers should ask clinicians to help improve the safety of their surgical car…
  3. psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
    September 01, 2007 - SPOTLIGHT CASE Out of Sight, Out of Mind: Out-of-Office Test Result Management Citation Text: Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36336/psn-pdf
    October 26, 2010 - Interprofessional Approaches to Patient Safety. October 26, 2010 J Interprof Care. 2006;20(5):461-563. https://psnet.ahrq.gov/issue/interprofessional-approaches-patient-safety This issue includes articles that explore successful multidisciplinary efforts to improve patient safety, including medication risk assessm…
  5. psnet.ahrq.gov/issue/application-human-factors-methods-understand-missed-follow-abnormal-test-results
    December 16, 2020 - Study Application of human factors methods to understand missed follow-up of abnormal test results. Citation Text: Rogith D, Satterly T, Singh H, et al. Application of human factors methods to understand missed follow-up of abnormal test results. Appl Clin Inform. 2020;11(05):692-698. do…
  6. psnet.ahrq.gov/issue/interprofessional-learning-multidisciplinary-healthcare-teams-associated-reduced-patient
    April 10, 2024 - Review Interprofessional learning in multidisciplinary healthcare teams is associated with reduced patient mortality: a quantitative systematic review and meta-analysis. Citation Text: Webster CS, Coomber T, Liu S, et al. Interprofessional learning in multidisciplinary healthcare teams i…
  7. psnet.ahrq.gov/issue/prevalence-and-characteristics-diagnostic-error-pediatric-critical-care-multicenter-study
    December 11, 2024 - Study Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study. Citation Text: Cifra CL, Custer JW, Smith CM, et al. Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study. Crit Care Med. 2023;51(11):14…
  8. psnet.ahrq.gov/issue/retrospective-evaluation-computerized-physician-order-entry-adaptation-prevent-prescribing
    May 27, 2011 - Study Retrospective evaluation of a computerized physician order entry adaptation to prevent prescribing errors in a pediatric emergency department. Citation Text: Sard BE, Walsh KE, Doros G, et al. Retrospective evaluation of a computerized physician order entry adaptation to prevent …
  9. psnet.ahrq.gov/issue/diagnostic-discrepancies-between-antemortem-clinical-diagnosis-and-autopsy-findings-pediatric
    July 28, 2021 - Study Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients. Citation Text: Raghuram N, Alodan K, Bartels U, et al. Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients.…
  10. psnet.ahrq.gov/issue/impact-digitally-acquired-peer-diagnostic-input-diagnostic-confidence-outpatient-cases
    June 15, 2022 - Study Impact of digitally acquired peer diagnostic input on diagnostic confidence in outpatient cases: a pragmatic randomized trial. Citation Text: Khoong EC, Fontil V, Rivadeneira NA, et al. Impact of digitally acquired peer diagnostic input on diagnostic confidence in outpatient cases:…
  11. psnet.ahrq.gov/issue/modified-early-warning-system-improves-patient-safety-and-clinical-outcomes-academic
    September 18, 2019 - Study Modified Early Warning System improves patient safety and clinical outcomes in an academic community hospital. Citation Text: Mathukia C, Fan WQ, Vadyak K, et al. Modified Early Warning System improves patient safety and clinical outcomes in an academic community hospital. J Commun…
  12. psnet.ahrq.gov/issue/reducing-risk-delayed-colorectal-cancer-diagnoses-through-ambulatory-safety-net-collaborative
    February 28, 2011 - Study Reducing the risk of delayed colorectal cancer diagnoses through an ambulatory safety net collaborative. Citation Text: Moyal-Smith R, Elam M, Boulanger J, et al. Reducing the risk of delayed colorectal cancer diagnoses through an ambulatory safety net collaborative. Jt Comm J Qual…
  13. psnet.ahrq.gov/issue/physician-transition-care-benefits-i-pass-and-electronic-handoff-system-community-pediatric
    November 02, 2022 - Study Physician transition of care: benefits of I-PASS and an electronic handoff system in a community pediatric residency program. Citation Text: Walia J, Qayumi Z, Khawar N, et al. Physician Transition of Care: Benefits of I-PASS and an Electronic Handoff System in a Community Pediatri…
  14. psnet.ahrq.gov/issue/development-research-agenda-identify-evidence-based-strategies-improve-physician-wellness-and
    June 01, 2022 - Commentary Development of a research agenda to identify evidence-based strategies to improve physician wellness and reduce burnout. Citation Text: Dyrbye LN, Trockel M, Frank E, et al. Development of a Research Agenda to Identify Evidence-Based Strategies to Improve Physician Wellness an…
  15. psnet.ahrq.gov/issue/description-and-evaluation-interprofessional-patient-safety-course-health-professions-and
    July 19, 2023 - Commentary Description and evaluation of an interprofessional patient safety course for health professions and related sciences students. Citation Text: Galt KA, Paschal KA, O'Brien RL, et al. Description and Evaluation of an Interprofessional Patient Safety Course for Health Professio…
  16. psnet.ahrq.gov/issue/managing-patient-safety-and-staff-safety-nursing-homes-exploring-how-leaders-nursing-homes
    September 13, 2023 - Study Managing patient safety and staff safety in nursing homes: exploring how leaders of nursing homes negotiate their dual responsibilities- a case study. Citation Text: Magerøy MR, Macrae C, Braut GS, et al. Managing patient safety and staff safety in nursing homes: exploring how lead…
  17. psnet.ahrq.gov/issue/multidisciplinary-multifaceted-improvement-initiative-eliminate-mislabelled-laboratory
    December 24, 2008 - Study A multidisciplinary, multifaceted improvement initiative to eliminate mislabelled laboratory specimens at a large tertiary care hospital. Citation Text: Seferian EG, Jamal S, Clark K, et al. A multidisciplinary, multifaceted improvement initiative to eliminate mislabelled laborator…
  18. psnet.ahrq.gov/issue/one-fourth-unplanned-transfers-higher-level-care-are-associated-highly-preventable-adverse
    May 16, 2018 - Study One fourth of unplanned transfers to a higher level of care are associated with a highly preventable adverse event: a patient record review in six Belgian hospitals. Citation Text: Marquet K, Claes N, De Troy E, et al. One fourth of unplanned transfers to a higher level of care are…
  19. psnet.ahrq.gov/issue/errors-administration-parenteral-drugs-intensive-care-units-multinational-prospective-study
    September 30, 2010 - Study Errors in administration of parenteral drugs in intensive care units: multinational prospective study. Citation Text: Valentin A, Capuzzo M, Guidet B, et al. Errors in administration of parenteral drugs in intensive care units: multinational prospective study. BMJ. 2009;338:b814.…
  20. psnet.ahrq.gov/issue/humanizing-harm-using-restorative-approach-heal-and-learn-adverse-events
    November 30, 2022 - Commentary Humanizing harm: using a restorative approach to heal and learn from adverse events. Citation Text: Wailling J, Kooijman A, Hughes J, et al. Humanizing harm: Using a restorative approach to heal and learn from adverse events. Health Expect. 2022;25(4):1192-1199. doi:10.1111/he…

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