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psnet.ahrq.gov/node/47009/psn-pdf
December 21, 2018 - Perceptions of rounding checklists in the intensive care
unit: a qualitative study.
December 21, 2018
Hallam BD, Kuza CC, Rak K, et al. Perceptions of rounding checklists in the intensive care unit: a
qualitative study. BMJ Qual Saf. 2018;27(10):836-843. doi:10.1136/bmjqs-2017-007218.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/837811/psn-pdf
August 10, 2022 - Examining the Status of VA’s Electronic Health Record
Modernization Program.
August 10, 2022
US Senate Committee on Veterans Affairs. 117th Cong (2021-2022). (July 20, 2022).
https://psnet.ahrq.gov/issue/examining-status-vas-electronic-health-record-modernization-program
Large-scale electronic health record (EHR) …
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psnet.ahrq.gov/node/45270/psn-pdf
June 29, 2016 - Using contemporary leadership skills in medication safety
programs.
June 29, 2016
Hertig JB, Hultgren KE, Weber RJ. Using Contemporary Leadership Skills in Medication Safety Programs.
Hosp Pharm. 2016;51(4):338-44. doi:10.1310/hpj5104-338.
https://psnet.ahrq.gov/issue/using-contemporary-leadership-skills-medicatio…
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psnet.ahrq.gov/node/46517/psn-pdf
November 01, 2017 - Joy in medical practice: clinician satisfaction in the
Healthy Work Place trial.
November 1, 2017
Linzer M, Sinsky CA, Poplau S, et al. Joy In Medical Practice: Clinician Satisfaction In The Healthy Work
Place Trial. Health Aff (Millwood). 2017;36(10):1808-1814. doi:10.1377/hlthaff.2017.0790.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/42382/psn-pdf
July 16, 2014 - Huddling for high reliability and situation awareness.
July 16, 2014
Goldenhar LM, Brady PW, Sutcliffe K, et al. Huddling for high reliability and situation awareness. BMJ Qual
Saf. 2013;22(11):899-906. doi:10.1136/bmjqs-2012-001467.
https://psnet.ahrq.gov/issue/huddling-high-reliability-and-situation-awareness
Se…
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psnet.ahrq.gov/node/43647/psn-pdf
November 12, 2014 - Mid Staffordshire NHS Foundation Trust Quality Report.
November 12, 2014
Newcastle Upon Tyne, UK: Care Quality Commission; October 9, 2014.
https://psnet.ahrq.gov/issue/mid-staffordshire-nhs-foundation-trust-quality-report
The Mid Staffordshire Trust has been under much scrutiny in recent years. This report highlig…
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psnet.ahrq.gov/node/836932/psn-pdf
April 13, 2022 - Nurses: Guilty verdict for dosing mistake could cost lives.
April 13, 2022
Loller T. Associated Press. March 30, 2022.
https://psnet.ahrq.gov/issue/nurses-guilty-verdict-dosing-mistake-could-cost-lives
Reporting medical errors, learning from them, and improving systems is a cornerstone of improving patien…
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psnet.ahrq.gov/node/48147/psn-pdf
July 24, 2019 - Patient Safety Ethics: How Vigilance, Mindfulness,
Compliance, and Humility can Make Healthcare Safer.
July 24, 2019
Banja JD. Baltimore, MD: Johns Hopkins University Press; 2019. ISBN: 9781421429083.
https://psnet.ahrq.gov/issue/patient-safety-ethics-how-vigilance-mindfulness-compliance-and-humility-can-
make-hea…
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psnet.ahrq.gov/node/46138/psn-pdf
May 31, 2017 - An innovative collaborative model of care for
undiagnosed complex medical conditions.
May 31, 2017
Nageswaran S, Donoghue N, Mitchell A, et al. An Innovative Collaborative Model of Care for Undiagnosed
Complex Medical Conditions. Pediatrics. 2017;139(5):e20163373. doi:10.1542/peds.2016-3373.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/48133/psn-pdf
November 01, 2024 - The NHS Patient Safety Strategy.
November 1, 2024
NHS England
https://psnet.ahrq.gov/issue/nhs-patient-safety-strategy
The United Kingdom National Health Service (NHS) has been at the forefront of patient safety innovation.
This strategy seeks to further implement approaches that explore and optimize the intersect…
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psnet.ahrq.gov/node/44749/psn-pdf
December 27, 2018 - Southern Baptist Hospital of Florida v. Charles.
December 27, 2018
Fla Ct App, 1st Dist. October 28, 2015.
https://psnet.ahrq.gov/issue/southern-baptist-hospital-florida-v-charles
The Patient Safety and Quality Improvement Act (PSQIA) provides federal protection of adverse event
reports voluntarily submitted to pa…
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psnet.ahrq.gov/node/72813/psn-pdf
March 10, 2021 - Racial/ethnic inequities in pregnancy-related morbidity
and mortality.
March 10, 2021
Minehart RD, Bryant AS, Jackson J, et al. Racial/ethnic inequities in pregnancy-related morbidity and
mortality. Obstet Gynecol Clin North Am. 2021;48(1):31-51. doi:10.1016/j.ogc.2020.11.005.
https://psnet.ahrq.gov/issue/racialet…
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psnet.ahrq.gov/node/47076/psn-pdf
August 15, 2018 - Incident learning in radiation oncology: a review.
August 15, 2018
Ford E, Evans SB. Incident learning in radiation oncology: A review. Med Phys. 2018;45(5):e100-e119.
doi:10.1002/mp.12800.
https://psnet.ahrq.gov/issue/incident-learning-radiation-oncology-review
Learning from adverse events is a core component of …
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psnet.ahrq.gov/node/60669/psn-pdf
July 08, 2020 - Participation in a system-thinking simulation experience
changes adverse event reporting.
July 8, 2020
Sanko JS, Mckay M. Participation in a system-thinking simulation experience changes adverse event
reporting. Simul Healthc. 2020;15(3):167-171. doi:10.1097/sih.0000000000000473.
https://psnet.ahrq.gov/issue/parti…
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psnet.ahrq.gov/node/45181/psn-pdf
June 22, 2016 - Strengthening leadership as a catalyst for enhanced
patient safety culture: a repeated cross-sectional
experimental study.
June 22, 2016
Kristensen S, Christensen KB, Jaquet A, et al. Strengthening leadership as a catalyst for enhanced patient
safety culture: a repeated cross-sectional experimental study. BMJ Open…
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psnet.ahrq.gov/node/42274/psn-pdf
May 22, 2013 - Duty-hour limits and patient care and resident outcomes:
can high-quality studies offer insight into complex
relationships?
May 22, 2013
Philibert I, Nasca TJ, Brigham T, et al. Duty-hour limits and patient care and resident outcomes: can high-
quality studies offer insight into complex relationships? Annu Rev Med…
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psnet.ahrq.gov/node/60878/psn-pdf
January 01, 2021 - Intervention study for the reduction of medication errors
in elderly trauma patients.
September 2, 2020
Parro Martín M de los Á, Muñoz García M, Delgado Silveira E, et al. Intervention study for the reduction of
medication errors in elderly trauma patients. J Eval Clin Pract. 2021;27(1):160-166. doi:10.1111/jep.134…
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psnet.ahrq.gov/node/74693/psn-pdf
January 26, 2022 - Including the reason for use on prescriptions sent to
pharmacists: scoping review.
January 26, 2022
Mercer K, Carter C, Burns C, et al. Including the reason for use on prescriptions sent to pharmacists:
scoping review. JMIR Hum Factors. 2021;8(4):e22325. doi:10.2196/22325.
https://psnet.ahrq.gov/issue/including-re…
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psnet.ahrq.gov/node/73075/psn-pdf
March 24, 2021 - Analysis of transdermal medication patch errors
uncovers a “patchwork” of safety challenges.
March 24, 2021
ISMP Medication Safety Alert! Acute Care. March 11, 2021;26(5):1-6.
https://psnet.ahrq.gov/issue/analysis-transdermal-medication-patch-errors-uncovers-patchwork-safety-
challenges
Skin patches are a conveni…
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psnet.ahrq.gov/node/842759/psn-pdf
January 18, 2023 - Cognitive aids in the management of clinical
emergencies: a systematic review.
January 18, 2023
Greig PR, Zolger D, Onwochei DN, et al. Cognitive aids in the management of clinical emergencies: a
systematic review. Anaesthesia. 2023;78(3):343-355. doi:10.1111/anae.15939.
https://psnet.ahrq.gov/issue/cognitive-aids…