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psnet.ahrq.gov/node/47158/psn-pdf
August 15, 2018 - A standardized handoff simulation promotes recovery
from auditory distractions in resident physicians.
August 15, 2018
Matern LH, Farnan JM, Hirsch KW, et al. A Standardized Handoff Simulation Promotes Recovery From
Auditory Distractions in Resident Physicians. Simul Healthc. 2018;13(4):233-238.
doi:10.1097/SIH.00…
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psnet.ahrq.gov/node/45571/psn-pdf
January 18, 2017 - How communication among members of the health care
team affects maternal morbidity and mortality.
January 18, 2017
Brennan RA, Keohane CA. How Communication Among Members of the Health Care Team Affects
Maternal Morbidity and Mortality. J Obstet Gynecol Neonatal Nurs. 2016;45(6):878-884.
doi:10.1016/j.jogn.2016.03…
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psnet.ahrq.gov/node/73140/psn-pdf
April 14, 2021 - Association between primary care physician diagnostic
knowledge and death, hospitalisation and emergency
department visits following an outpatient visit at risk for
diagnostic error: a retrospective cohort study using
medicare claims.
April 14, 2021
Gray BM, Vandergrift JL, McCoy RG, et al. Association between pr…
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psnet.ahrq.gov/issue/vha-national-patient-safety-improvement-handbook
April 12, 2019 - Organizational Policy/Guidelines
VHA National Patient Safety Improvement Handbook.
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January 17, 2012
A handbook developed by the …
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psnet.ahrq.gov/node/44459/psn-pdf
October 06, 2016 - Examining the Relationship Between Health IT and
Ambulatory Care Workflow Redesign.
October 6, 2016
Zheng K, Ciemins EL, Lanham HJ, et al. Rockville, MD: Agency for Healthcare Research and Quality; July
2015. AHRQ Publication No. 15-0058-EF.
https://psnet.ahrq.gov/issue/examining-relationship-between-health-it-and…
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psnet.ahrq.gov/node/34649/psn-pdf
June 11, 2014 - On error management: lessons from aviation.
June 11, 2014
Helmreich RL. On error management: lessons from aviation. BMJ . 2000;320(7237):781-785.
https://psnet.ahrq.gov/issue/error-management-lessons-aviation
In this perspective, the author draws on analogies from aviation to frame the issues of patient safety and
…
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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/44628/psn-pdf
September 12, 2016 - Rates of safety incident reporting in MRI in a large
academic medical center.
September 12, 2016
Mansouri M, Aran S, Harvey HB, et al. Rates of safety incident reporting in MRI in a large academic
medical center. J Magn Reson Imaging. 2016;43(4):998-1007. doi:10.1002/jmri.25055.
https://psnet.ahrq.gov/issue/rates-…
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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/36025/psn-pdf
March 28, 2011 - Understanding diagnostic errors in medicine: a lesson
from aviation.
March 28, 2011
Singh H, Petersen LA, Thomas EJ. Understanding diagnostic errors in medicine: a lesson from aviation.
Qual Saf Health Care. 2006;15(3):159-64.
https://psnet.ahrq.gov/issue/understanding-diagnostic-errors-medicine-lesson-aviation
T…
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psnet.ahrq.gov/node/38400/psn-pdf
February 11, 2009 - The impact of clinically undiagnosed injuries on survival
estimates.
February 11, 2009
Gedeborg R, Thiblin I, Byberg L, et al. The impact of clinically undiagnosed injuries on survival estimates.
Crit Care Med. 2009;37(2). doi:10.1097/ccm.0b013e318194b164.
https://psnet.ahrq.gov/issue/impact-clinically-undiagnosed…
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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/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/45152/psn-pdf
November 18, 2016 - Department of Veterans Affairs Chief Resident in Quality
and Patient Safety Program: a model to spread change.
November 18, 2016
Watts B, Paull DE, Williams LC, et al. Department of Veterans Affairs Chief Resident in Quality and Patient
Safety Program: A Model to Spread Change. Am J Med Qual. 2016;31(6):598-600.
h…
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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/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…
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psnet.ahrq.gov/node/45720/psn-pdf
April 13, 2017 - Medical morbidity and mortality conferences: past,
present and future.
April 13, 2017
George J. Medical morbidity and mortality conferences: past, present and future. Postgrad Med J.
2017;93(1097):148-152. doi:10.1136/postgradmedj-2016-134103.
https://psnet.ahrq.gov/issue/medical-morbidity-and-mortality-conference…