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psnet.ahrq.gov/node/43269/psn-pdf
July 28, 2014 - Restoring trust in VA health care.
July 28, 2014
Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med. 2014;371(4):295-297.
doi:10.1056/NEJMp1406852.
https://psnet.ahrq.gov/issue/restoring-trust-va-health-care
In response to a recent investigation raising concerns about inaccurate reporting of wait-ti…
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psnet.ahrq.gov/node/47387/psn-pdf
September 12, 2018 - Guideline implementation: team communication.
September 12, 2018
Link T. Guideline Implementation: Team Communication: 1.8 www.aornjournal.org/content/cme. AORN J.
2018;108(2):165-177. doi:10.1002/aorn.12300.
https://psnet.ahrq.gov/issue/guideline-implementation-team-communication
Although team development has rec…
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psnet.ahrq.gov/node/47412/psn-pdf
October 31, 2018 - The systems approach at the sharp end.
October 31, 2018
Cross SRH. The systems approach at the sharp end. Future Healthc J. 2019;5(3):176-180.
doi:10.7861/futurehosp.5-3-176.
https://psnet.ahrq.gov/issue/systems-approach-sharp-end
Systems solutions are often focused on creating improvements at the organizational o…
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psnet.ahrq.gov/node/45363/psn-pdf
September 14, 2016 - Effective perioperative communication to enhance patient
care.
September 14, 2016
Garrett H. Effective Perioperative Communication to Enhance Patient Care. AORN J. 2016;104(2):111-20.
doi:10.1016/j.aorn.2016.06.001.
https://psnet.ahrq.gov/issue/effective-perioperative-communication-enhance-patient-care
Poor team …
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psnet.ahrq.gov/node/47712/psn-pdf
February 20, 2019 - A cognitive forcing tool to mitigate cognitive bias—a
randomised control trial.
February 20, 2019
O'Sullivan ED, Schofield SJ. A cognitive forcing tool to mitigate cognitive bias - a randomised control trial.
BMC Med Educ. 2019;19(1):12. doi:10.1186/s12909-018-1444-3.
https://psnet.ahrq.gov/issue/cognitive-forcing…
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psnet.ahrq.gov/node/45930/psn-pdf
April 26, 2017 - A boy's life is lost to sepsis. Thousands are saved in his
wake.
April 26, 2017
Dwyer J. New York Times. April 13, 2017.
https://psnet.ahrq.gov/issue/boys-life-lost-sepsis-thousands-are-saved-his-wake
Stories of patient harm due to medical mistakes can serve as catalysts for organizational improvement.
This newsp…
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psnet.ahrq.gov/node/45303/psn-pdf
June 15, 2017 - The global burden of diagnostic errors in primary care.
June 15, 2017
Singh H, Schiff G, Graber ML, et al. The global burden of diagnostic errors in primary care. BMJ Qual Saf.
2017;26(6):484-494. doi:10.1136/bmjqs-2016-005401.
https://psnet.ahrq.gov/issue/global-burden-diagnostic-errors-primary-care
The need to i…
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psnet.ahrq.gov/node/47114/psn-pdf
October 13, 2018 - Focused ethnography of diagnosis in academic medical
centers.
October 13, 2018
Chopra V, Harrod M, Winter S, et al. Focused Ethnography of Diagnosis in Academic Medical Centers. J
Hosp Med. 2018;13(10):668-672. doi:10.12788/jhm.2966.
https://psnet.ahrq.gov/issue/focused-ethnography-diagnosis-academic-medical-cente…
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psnet.ahrq.gov/node/45477/psn-pdf
October 05, 2016 - Promoting safety through well-being: an experience in
healthcare.
October 5, 2016
Bruno A, Bracco F. Promoting Safety through Well-Being: An Experience in Healthcare. Front Psychol.
2016;7:1208. doi:10.3389/fpsyg.2016.01208.
https://psnet.ahrq.gov/issue/promoting-safety-through-well-being-experience-healthcare
Th…
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psnet.ahrq.gov/node/38929/psn-pdf
April 01, 2010 - Effectiveness of patient care teams and the role of clinical
expertise and coordination: a literature review.
April 1, 2010
Bosch M, Faber MJ, Cruijsberg J, et al. Review article: Effectiveness of patient care teams and the role of
clinical expertise and coordination: a literature review. Med Care Res Rev. 2009;66(…
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psnet.ahrq.gov/node/836871/psn-pdf
April 06, 2022 - The spectrum of harm associated with modern medicine.
April 6, 2022
Schattner A. The spectrum of harm associated with modern medicine. J Gen Intern Med. 2022;37(3):664-
667. doi:10.1007/s11606-021-06997-x.
https://psnet.ahrq.gov/issue/spectrum-harm-associated-modern-medicine
Interest in harm resulting from medical…
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psnet.ahrq.gov/node/44442/psn-pdf
August 26, 2015 - How your hospital can make you sick.
August 26, 2015
Consumer Reports. July 29, 2015.
https://psnet.ahrq.gov/issue/how-your-hospital-can-make-you-sick
This news article reports on health care–associated infections, particularly Clostridium difficile and
methicillin-resistant Staphylococcus aureus, discusses ways h…
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psnet.ahrq.gov/node/73359/psn-pdf
June 02, 2020 - Patient Safety Movement Foundation.
June 2, 2020
15642 Sand Canyon Ave. #51268, Irvine, CA 92619. 877-236-0279, info@psmf.org.
https://psnet.ahrq.gov/issue/patient-safety-movement-foundation
This organization shares best practices to align and optimize efforts toward eliminating patient harm by the
…
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psnet.ahrq.gov/node/73543/psn-pdf
July 28, 2021 - AMC PSO Resource Center.
July 28, 2021
Academic Medical Center Patient Safety Organization.
https://psnet.ahrq.gov/issue/amc-pso-resource-center
Patient Safety organizations (PSO) are in a unique position to educate their members and the larger
community on patient safety challenges. This PSO resource collection i…
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psnet.ahrq.gov/node/72515/psn-pdf
January 15, 2025 - AHRQ’s Surveys on Patient Safety Culture® Program: An
Overview for New Users.
December 17, 2024
Rockville, MD: Agency for Healthcare Research and Quality. January 15, 2025.
https://psnet.ahrq.gov/issue/tutorial-ahrq-sopsr-data-entry-and-analysis-tool
An organization’s understanding of its culture is foundational t…
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psnet.ahrq.gov/node/43898/psn-pdf
February 11, 2015 - Special Section on Patient Safety and Quality in
Healthcare.
February 11, 2015
Andersen HB, Lipczak H, Borch-Johnsen K, eds. Cogn Technol Work. 2015;17:1-155.
https://psnet.ahrq.gov/issue/special-section-patient-safety-and-quality-healthcare
Articles in this special issue explore patient safety from a sociotechnic…
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psnet.ahrq.gov/node/46698/psn-pdf
February 07, 2018 - Enhancing the quality and safety of the perioperative
patient.
February 7, 2018
Staender S, Smith A. Enhancing the quality and safety of the perioperative patient. Curr Opin Anaesthesiol.
2017;30(6):730-735. doi:10.1097/ACO.0000000000000517.
https://psnet.ahrq.gov/issue/enhancing-quality-and-safety-perioperative-p…
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psnet.ahrq.gov/node/48111/psn-pdf
July 10, 2019 - Medication Safety in Key Action Areas.
July 10, 2019
Geneva, Switzerland: World Health Organization; 2019.
https://psnet.ahrq.gov/issue/medication-safety-key-action-areas
Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores
key areas of concern that require act…
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psnet.ahrq.gov/node/45386/psn-pdf
November 23, 2016 - Balancing doctor egos and errors.
November 23, 2016
Sweeney JF. Medical Economics. November 10, 2016.
https://psnet.ahrq.gov/issue/balancing-doctor-egos-and-errors
Disclosure and candor with patients after a medical error has gained support from organizations, clinicians,
and patients. This magazine article discus…
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psnet.ahrq.gov/node/37895/psn-pdf
July 09, 2008 - Accidents, claiming, and regional subcultures: are
medical errors and malpractice lawsuits related to social
capital?
July 9, 2008
Williams J. Accidents, claiming, and regional subcultures: Are medical errors and malpractice lawsuits
related to social capital? J Safety Res. 2008;39(3). doi:10.1016/j.jsr.2008.01.00…