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psnet.ahrq.gov/node/43909/psn-pdf
March 11, 2015 - Summary and frequency of barriers to adoption of CPOE
in the US.
March 11, 2015
Kruse CS, Goetz K. Summary and frequency of barriers to adoption of CPOE in the U.S. J Med Syst.
2015;39(2):15. doi:10.1007/s10916-015-0198-2.
https://psnet.ahrq.gov/issue/summary-and-frequency-barriers-adoption-cpoe-us
Although compu…
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psnet.ahrq.gov/node/38057/psn-pdf
September 10, 2008 - Randomized controlled trial of a pictogram-based
intervention to reduce liquid medication dosing errors
and improve adherence among caregivers of young
children.
September 10, 2008
Yin S, Dreyer BP, van Schaick L, et al. Randomized controlled trial of a pictogram-based intervention to
reduce liquid medication do…
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psnet.ahrq.gov/node/34921/psn-pdf
February 27, 2009 - A controlled trial of smart infusion pumps to improve
medication safety in critically ill patients.
February 27, 2009
Rothschild JM, Keohane C, Cook F, et al. A controlled trial of smart infusion pumps to improve medication
safety in critically ill patients. Crit Care Med. 2005;33(3):533-540.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/47215/psn-pdf
September 19, 2018 - The application of system dynamics modelling to system
safety improvement: present use and future potential.
September 19, 2018
Ibrahim M; Gyuchan S; Jun GT; Robinson S. Safety Sci. 2018;106:104-120.
https://psnet.ahrq.gov/issue/application-system-dynamics-modelling-system-safety-improvement-present-
use-and-futur…
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psnet.ahrq.gov/node/45505/psn-pdf
July 01, 2017 - A model for the departmental quality management
infrastructure within an academic health system.
July 1, 2017
Mathews SC, Demski R, Hooper JE, et al. A Model for the Departmental Quality Management
Infrastructure Within an Academic Health System. Acad Med. 2017;92(5):608-613.
doi:10.1097/ACM.0000000000001380.
htt…
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psnet.ahrq.gov/node/45983/psn-pdf
June 27, 2018 - Educating for the 21st-century health care system: an
interdependent framework of basic, clinical, and systems
sciences.
June 27, 2018
Gonzalo JD, Haidet P, Papp KK, et al. Educating for the 21st-Century Health Care System: An
Interdependent Framework of Basic, Clinical, and Systems Sciences. Acad Med. 2017;92(1):…
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psnet.ahrq.gov/node/866395/psn-pdf
July 23, 2024 - Sustaining This Innovation
The following elements are key to sustaining this innovation:
Incorporate
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psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - An implementation resource that healthcare organizations can use to incorporate NPSGs into their daily
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psnet.ahrq.gov/node/37569/psn-pdf
March 21, 2017 - How often are potential patient safety events present on
admission?
March 21, 2017
Houchens RL, Elixhauser A, Romano PS. How often are potential patient safety events present on
admission? Jt Comm J Qual Patient Saf. 2008;34(3):154-63.
https://psnet.ahrq.gov/issue/how-often-are-potential-patient-safety-events-pres…
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psnet.ahrq.gov/node/46467/psn-pdf
October 18, 2017 - The Role of Clinical Learning Environments in Preparing
New Clinicians to Engage in Patient Safety.
October 18, 2017
Disch J, Kilo CM, Passiment M, Wagner R, Weiss KB; National Collaborative for Improving the Clinical
Learning Environment. Chicago, IL: Accreditation Council for Graduate Medical Education; 2017.
ht…
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psnet.ahrq.gov/node/38033/psn-pdf
September 24, 2010 - Implementing online medication reconciliation at a large
academic medical center.
September 24, 2010
Bails D, Clayton K, Roy K, et al. Implementing online medication reconciliation at a large academic medical
center. Jt Comm J Qual Patient Saf. 2008;34(9):499-508.
https://psnet.ahrq.gov/issue/implementing-online-m…
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psnet.ahrq.gov/node/38517/psn-pdf
February 17, 2011 - Use of electronic health records in US hospitals.
February 17, 2011
Jha AK, DesRoches CM, Campbell EG, et al. Use of electronic health records in U.S. hospitals.
doi:10.1056/NEJMsa0900592.
https://psnet.ahrq.gov/issue/use-electronic-health-records-us-hospitals
Increasing the use of electronic health records (EHRs)…
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psnet.ahrq.gov/node/36784/psn-pdf
February 24, 2011 - The many faces of error disclosure: a common set of
elements and a definition.
February 24, 2011
Fein SP, Hilborne LH, Spiritus EM, et al. The many faces of error disclosure: a common set of elements
and a definition. J Gen Intern Med. 2007;22(6):755-761.
https://psnet.ahrq.gov/issue/many-faces-error-disclosure-co…
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psnet.ahrq.gov/node/44238/psn-pdf
November 03, 2015 - Use of temporary names for newborns and associated
risks.
November 3, 2015
Adelman JS, Aschner JL, Schechter CB, et al. Use of Temporary Names for Newborns and Associated
Risks. Pediatrics. 2015;136(2):327-333. doi:10.1542/peds.2015-0007.
https://psnet.ahrq.gov/issue/use-temporary-names-newborns-and-associated-ris…
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psnet.ahrq.gov/node/43999/psn-pdf
May 19, 2018 - Label design affects medication safety in an operating
room crisis: a controlled simulation study.
May 19, 2018
Estock JL, Murray AW, Mizah MT, et al. Label Design Affects Medication Safety in an Operating Room
Crisis: A Controlled Simulation Study. J Patient Saf. 2018;14(2):101-106.
doi:10.1097/PTS.00000000000001…
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psnet.ahrq.gov/node/44518/psn-pdf
January 22, 2016 - Embracing errors in simulation-based training: the effect
of error training on retention and transfer of central
venous catheter skills.
January 22, 2016
Gardner AK, Abdelfattah K, Wiersch J, et al. Embracing Errors in Simulation-Based Training: The Effect of
Error Training on Retention and Transfer of Central Ven…
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psnet.ahrq.gov/node/45594/psn-pdf
December 19, 2017 - Teaching quality improvement and patient safety in
residency education: strategies for meaningful resident
quality and safety initiatives.
December 19, 2017
Morrison RJ, Bowe SN, Brenner MJ. Teaching Quality Improvement and Patient Safety in Residency
Education: Strategies for Meaningful Resident Quality and Safet…
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psnet.ahrq.gov/node/47482/psn-pdf
December 05, 2018 - Examining the effects of an obstetrics interprofessional
programme on reductions to reportable events and their
related costs.
December 5, 2018
Geary M, Ruiter PJA, Yasseen AS. Examining the effects of an obstetrics interprofessional programme on
reductions to reportable events and their related costs. J Interprof…
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psnet.ahrq.gov/node/35540/psn-pdf
August 05, 2009 - Lost in translation: challenges and opportunities in
physician-to-physician communication during patient
handoffs.
August 5, 2009
Solet DJ, Norvell M, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-
physician communication during patient handoffs. Acad Med. 2005;80(12):1094-9.
…
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psnet.ahrq.gov/node/45340/psn-pdf
August 17, 2016 - To the point: integrating patient safety education Into the
obstetrics and gynecology undergraduate curriculum.
August 17, 2016
Abbott JF, Pradhan A, Buery-Joyner S, et al. To the Point: Integrating Patient Safety Education Into the
Obstetrics and Gynecology Undergraduate Curriculum. J Patient Saf. 2016;16(1):e39-e…