-
psnet.ahrq.gov/periodic-issue/periodic-issue-471
December 31, 2024 - January 22, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
-
psnet.ahrq.gov/node/41359/psn-pdf
November 21, 2016 - The relationship between organizational culture and
family satisfaction in critical care.
November 21, 2016
Dodek P, Wong H, Heyland DK, et al. The relationship between organizational culture and family
satisfaction in critical care. Crit Care Med. 2012;40(5):1506-12. doi:10.1097/CCM.0b013e318241e368.
https://psne…
-
psnet.ahrq.gov/node/859349/psn-pdf
January 01, 2024 - Investigating the influence of selected leadership styles
on patient safety and quality of care: a systematic review
and meta-analysis.
December 20, 2023
Singh A, Yeravdekar R, Jadhav S. Investigating the influence of selected leadership styles on patient safety
and quality of care: a systematic review and meta-an…
-
psnet.ahrq.gov/node/45519/psn-pdf
November 01, 2017 - Morbidity and mortality conferences: a narrative review of
strategies to prioritize quality improvement.
November 1, 2017
Giesbrecht V, Au S. Morbidity and Mortality Conferences: A Narrative Review of Strategies to Prioritize
Quality Improvement. Jt Comm J Qual Patient Saf. 2016;42(11):516-527. doi:10.1016/S1553-
…
-
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…
-
psnet.ahrq.gov/node/47909/psn-pdf
May 29, 2019 - Teaching novice clinicians how to reduce diagnostic
waste and errors by applying the Toyota Production
System.
May 29, 2019
Radhakrishnan NS, Singh H, Southwick FS. Teaching novice clinicians how to reduce diagnostic waste
and errors by applying the Toyota Production System. Diagnosis (Berl). 2019;6(2):179-185. do…
-
psnet.ahrq.gov/node/50418/psn-pdf
January 01, 2020 - Experiential learning through local implementation of a
national chief resident in quality and patient safety
curriculum.
September 1, 2019
Ronan MV, Menon A, Swamy L, et al. Experiential Learning Through Local Implementation of a National
Chief Resident in Quality and Patient Safety Curriculum. American Journal o…
-
psnet.ahrq.gov/node/866959/psn-pdf
October 16, 2024 - A review of incidents related to health information
technology in Swedish healthcare to characterise system
issues as a basis for improvement in clinical practice.
October 16, 2024
Pan D, Nilsson E, Rahman Jabin MS. A review of incidents related to health information technology in
Swedish healthcare to characteris…
-
psnet.ahrq.gov/node/867751/psn-pdf
March 12, 2025 - Epidemiology of diagnostic errors in pediatric emergency
departments using electronic triggers.
March 12, 2025
Mahajan P, White E, Shaw KN, et al. Epidemiology of diagnostic errors in pediatric emergency
departments using electronic triggers. Acad Emerg Med. 2025;Epub Jan 15. doi:10.1111/acem.15087.
https://psnet.…
-
psnet.ahrq.gov/node/836988/psn-pdf
April 27, 2022 - Effect of the surgical safety checklist on provider and
patient outcomes: a systematic review.
April 27, 2022
Armstrong BA, Dutescu IA, Nemoy L, et al. Effect of the surgical safety checklist on provider and patient
outcomes: a systematic review. BMJ Qual Saf. 2022;31(6):463-478. doi:10.1136/bmjqs-2021-014361.
htt…
-
psnet.ahrq.gov/node/73211/psn-pdf
May 05, 2021 - The effectiveness of interruptive prescribing alerts in
ambulatory CPOE to change prescriber behaviour and
improve safety.
May 5, 2021
Cerqueira O, Gill M, Swar B, et al. The effectiveness of interruptive prescribing alerts in ambulatory CPOE
to change prescriber behaviour and improve safety. BMJ Qual Saf. 2021;30…
-
psnet.ahrq.gov/node/861774/psn-pdf
January 31, 2024 - Grand rounds in methodology: key considerations for
implementing machine learning solutions in quality
improvement initiatives.
January 31, 2024
Verma AA, Trbovich PL, Mamdani MM, et al. Grand rounds in methodology: key considerations for
implementing machine learning solutions in quality improvement initiatives. …
-
psnet.ahrq.gov/node/850910/psn-pdf
June 21, 2023 - Developing electronic clinical quality measures to assess
the cancer diagnostic process.
June 21, 2023
Murphy DR, Zimolzak AJ, Upadhyay DK, et al. Developing electronic clinical quality measures to assess
the cancer diagnostic process. J Am Med Inform Assoc. 2023;30(9):1526-1531.
doi:10.1093/jamia/ocad089.
https:…
-
psnet.ahrq.gov/node/838024/psn-pdf
September 07, 2022 - Overriding drug-drug interaction alerts in clinical decision
support systems: a scoping review.
September 7, 2022
Villa Zapata L, Subbian V, Boyce RD, et al. Overriding drug-drug interaction alerts in clinical decision
support systems: a scoping review. Stud Health Technol Inform. 2022;290:380-384.
doi:10.3233/sht…
-
psnet.ahrq.gov/node/74700/psn-pdf
January 26, 2022 - Differential diagnosis checklists reduce diagnostic error
differentially: a randomised experiment.
January 26, 2022
Kämmer JE, Schauber SK, Hautz SC, et al. Differential diagnosis checklists reduce diagnostic error
differentially: a randomised experiment. Med Educ. 2021;55(10):1172-1182. doi:10.1111/medu.14596.
ht…
-
psnet.ahrq.gov/node/866109/psn-pdf
June 12, 2024 - Grading recommendations for enhanced patient safety in
sentinel event analysis: the recommendation
improvement matrix.
June 12, 2024
Bos K, van der Laan MJ, Groeneweg J, et al. Grading recommendations for enhanced patient safety in
sentinel event analysis: the recommendation improvement matrix. BMJ Open Qual. 2024…
-
psnet.ahrq.gov/node/61122/psn-pdf
January 01, 2022 - Implementing high-reliability organization principles into
practice: a rapid evidence review.
November 11, 2020
Veazie S, Peterson K, Bourne D, et al. Implementing high-reliability organization principles into practice: a
rapid evidence review. J Patient Saf. 2022;18(1):e320-e328. doi:10.1097/pts.0000000000000768.
…
-
psnet.ahrq.gov/node/40191/psn-pdf
May 28, 2014 - The Value of Close Calls in Improving Patient Safety.
May 28, 2014
Wu AW, ed. Oakbrook Terrace, IL: Joint Commission Resources; 2011. ISBN: 9781599404158.
https://psnet.ahrq.gov/issue/value-close-calls-improving-patient-safety
Close calls (sometimes called near misses) pose unique challenges and opportunities when …
-
psnet.ahrq.gov/node/849610/psn-pdf
May 31, 2023 - Implementation of ED I-PASS as a standardized handoff
tool in the pediatric emergency department.
May 31, 2023
Yanni E, Calaman S, Wiener E, et al. Implementation of ED I-PASS as a standardized handoff tool in the
pediatric emergency department. J Healthc Qual. 2023;45(3):140-147.
doi:10.1097/jhq.0000000000000374.…
-
psnet.ahrq.gov/node/836960/psn-pdf
April 20, 2022 - Effect of a multispecialty faculty handoff initiative on
safety culture and handoff quality.
April 20, 2022
Fitzgerald KM, Banerjee TR, Starmer AJ, et al. Effect of a multispecialty faculty handoff initiative on safety
culture and handoff quality. Pediatr Qual Saf. 2022;7(2):e539. doi:10.1097/pq9.0000000000000539.
…