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psnet.ahrq.gov/node/849602/psn-pdf
May 31, 2023 - Psychosocial processes in healthcare workers: how
individuals' perceptions of interpersonal communication
is related to patient safety threats and higher-quality care.
May 31, 2023
Dietl JE, Derksen C, Keller FM, et al. Psychosocial processes in healthcare workers: how individuals'
perceptions of interpersonal com…
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psnet.ahrq.gov/node/46142/psn-pdf
June 14, 2017 - Introducing a new junior doctor electronic weekend
handover on an orthopaedic ward.
June 14, 2017
Maroo S, Raj D. Introducing a New Junior Doctor Electronic Weekend Handover on an Orthopaedic Ward.
BMJ Qual Improv Rep. 2017;6(1). doi:10.1136/bmjquality.u212695.w5059.
https://psnet.ahrq.gov/issue/introducing-new-ju…
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psnet.ahrq.gov/node/41132/psn-pdf
March 13, 2012 - Spreading a medication administration intervention
organizationwide in six hospitals.
March 13, 2012
Kliger J, Singer SJ, Hoffman F, et al. Spreading a medication administration intervention organizationwide
in six hospitals. Jt Comm J Qual Patient Saf. 2012;38(2):51-60.
https://psnet.ahrq.gov/issue/spreading-medi…
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psnet.ahrq.gov/node/47725/psn-pdf
March 06, 2019 - Overcoming human barriers to safety event reporting in
radiology.
March 6, 2019
Siewert B, Brook OR, Swedeen S, et al. Overcoming Human Barriers to Safety Event Reporting in
Radiology. Radiographics. 2019;39(1):251-263. doi:10.1148/rg.2019180135.
https://psnet.ahrq.gov/issue/overcoming-human-barriers-safety-event-…
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psnet.ahrq.gov/node/73114/psn-pdf
April 07, 2021 - Clinical and financial implications of second-opinion
surgical pathology review.
April 7, 2021
Johnson SM, Samulski TD, O’Connor SM, et al. Clinical and financial implications of second-opinion
surgical pathology review. Am J Clin Pathol. 2021;156(4):559-568. doi:10.1093/ajcp/aqaa263.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/47327/psn-pdf
August 22, 2018 - US internal medicine program director perceptions of
alignment of graduate medical education and institutional
resources for engaging residents in quality and safety.
August 22, 2018
Chacko KM, Halvorsen AJ, Swenson SL, et al. US Internal Medicine Program Director Perceptions of
Alignment of Graduate Medical Educa…
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psnet.ahrq.gov/node/862131/psn-pdf
February 07, 2024 - Prospective study of the multisite spread of a medication
safety intervention: factors common to hospitals with
improved outcomes.
February 7, 2024
Kaplan HC, Goldstein SL, Rubinson C, et al. Prospective study of the multisite spread of a medication
safety intervention: factors common to hospitals with improved ou…
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psnet.ahrq.gov/node/35392/psn-pdf
June 16, 2011 - Measuring patient safety climate: a review of surveys.
June 16, 2011
Colla JB, Bracken AC, Kinney LM, et al. Measuring patient safety climate: a review of surveys. Qual Saf
Health Care. 2005;14(5):364-6.
https://psnet.ahrq.gov/issue/measuring-patient-safety-climate-review-surveys
This systematic review compares th…
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psnet.ahrq.gov/node/45960/psn-pdf
January 01, 2021 - Informing the design of a new pragmatic registry to
stimulate near miss reporting in ambulatory care.
March 15, 2017
Pfoh ER, Engineer L, Singh H, et al. Informing the Design of a New Pragmatic Registry to Stimulate Near
Miss Reporting in Ambulatory Care. J Patient Saf. 2021;17(3):e121-e127.
doi:10.1097/PTS.000000…
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psnet.ahrq.gov/node/73067/psn-pdf
March 24, 2021 - Changes in error patterns in unanticipated trauma deaths
during 20 years: in pursuit of zero preventable deaths.
March 24, 2021
LaGrone LN, McIntyre LK, Riggle A, et al. Changes in error patterns in unanticipated trauma deaths during
20 years: In pursuit of zero preventable deaths. J Trauma Acute Care Surg. 2020;89…
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psnet.ahrq.gov/node/44753/psn-pdf
April 12, 2019 - Is bias in the eye of the beholder? A vignette study to
assess recognition of cognitive biases in clinical case
workups.
April 12, 2019
Zwaan L, Monteiro SD, Sherbino J, et al. Is bias in the eye of the beholder? A vignette study to assess
recognition of cognitive biases in clinical case workups. BMJ Qual Saf. 201…
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psnet.ahrq.gov/node/846751/psn-pdf
March 29, 2023 - High-fidelity simulation’s impact on clinical reasoning and
patient safety: a scoping review.
March 29, 2023
El Hussein MT, Hirst SP. High-fidelity simulation’s impact on clinical reasoning and patient safety: a
scoping review. J Nurs Reg. 2023;13(4):54-65. doi:10.1016/s2155-8256(23)00028-5.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/72790/psn-pdf
March 03, 2021 - Parent engagement in perinatal mortality reviews: an
online survey of clinicians from six high-income
countries.
March 3, 2021
Boyle FM, Horey D, Siassakos D, et al. Parent engagement in perinatal mortality reviews: an online survey
of clinicians from six high?income countries. BJOG. 2020;128(4):696-703. doi:10.11…
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psnet.ahrq.gov/node/837796/psn-pdf
August 10, 2022 - Association between hospital acquired harm outcomes
and membership in a national patient safety collaborative.
August 10, 2022
Coffey M, Marino M, Lyren A, et al. Association between hospital acquired harm outcomes and
membership in a national patient safety collaborative. JAMA Pediatr. 2022;176(9):924-932.
doi:10…
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psnet.ahrq.gov/node/46372/psn-pdf
September 13, 2017 - Impact of a successful speaking up program on health-
care worker hand hygiene behavior.
September 13, 2017
Linam MW; Honeycutt MD; Gilliam CH; Wisdom CM; Deshpande JK.
https://psnet.ahrq.gov/issue/impact-successful-speaking-program-health-care-worker-hand-hygiene-
behavior
Improving hand hygiene in health care f…
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psnet.ahrq.gov/node/72804/psn-pdf
March 03, 2021 - How to do no harm: empowering local leaders to make
care safer in low-resource settings.
March 3, 2021
Vincent CA, Mboga M, Gathara D, et al. How to do no harm: empowering local leaders to make care safer
in low-resource settings. Arch Dis Child. 2021;106(4):333-337. doi:10.1136/archdischild-2020-320631.
https://p…
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psnet.ahrq.gov/node/42115/psn-pdf
March 20, 2013 - Medication reconciliation during transitions of care as a
patient safety strategy: a systematic review.
March 20, 2013
Kwan JL, Lo L, Sampson M, et al. Medication reconciliation during transitions of care as a patient safety
strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):397-403. doi:10.7326/0003-4…
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psnet.ahrq.gov/node/37348/psn-pdf
March 28, 2012 - Impact of duty hours restrictions on quality of care and
clinical outcomes.
March 28, 2012
Bhavsar J, Montgomery D, Li J, et al. Impact of duty hours restrictions on quality of care and clinical
outcomes. Am J Med. 2007;120(11):968-74.
https://psnet.ahrq.gov/issue/impact-duty-hours-restrictions-quality-care-and-cl…
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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…
-
psnet.ahrq.gov/node/49656/psn-pdf
June 01, 2012 - Comanagement: Who's in Charge?
June 1, 2012
Cheng HQ. Comanagement: Who's in Charge? PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/comanagement-whos-charge
The Case
A 77-year-old man with a history of chronic obstructive pulmonary disease (COPD) was admitted with a left
hip fracture to the orthopedic surg…