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psnet.ahrq.gov/node/41676/psn-pdf
September 24, 2016 - Taking a detour: positive and negative effects of
supervisors' interruptions during admission case review
discussions.
September 24, 2016
Goldszmidt M, Aziz N, Lingard LA. Taking a detour: positive and negative effects of supervisors'
interruptions during admission case review discussions. Acad Med. 2012;87(10):13…
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psnet.ahrq.gov/node/38574/psn-pdf
November 21, 2016 - Family-identified barriers to medication reconciliation.
November 21, 2016
Riley-Lawless K. Family-identified barriers to medication reconciliation. J Spec Pediatr Nurs.
2009;14(2):94-101. doi:10.1111/j.1744-6155.2009.00182.x.
https://psnet.ahrq.gov/issue/family-identified-barriers-medication-reconciliation
Medica…
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psnet.ahrq.gov/node/863224/psn-pdf
February 28, 2024 - Special Section: IEA Health Care 2021.
February 28, 2024
Hum Factors. 2024;66(3):633-769.
https://psnet.ahrq.gov/issue/special-section-iea-health-care-2021
The ergonomics community has an established interest in medical error reduction. The 2021 International
Ergonomics Association conference examined applications…
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psnet.ahrq.gov/node/35302/psn-pdf
July 14, 2009 - Technology induced error and usability: the relationship
between usability problems and prescription errors when
using a handheld application.
July 14, 2009
Kushniruk AW, Triola MM, Borycki EM, et al. Technology induced error and usability: The relationship
between usability problems and prescription errors when u…
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psnet.ahrq.gov/node/45006/psn-pdf
April 06, 2016 - Quality and Patient Safety.
April 6, 2016
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/quality-and-patient-safety
The Agency for Healthcare Research and Quality has provided access to patient safety research,
information, and tools for nearly two decades. This website offers a wide rang…
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psnet.ahrq.gov/node/60024/psn-pdf
March 11, 2020 - Artificial intelligence and surgical decision-making.
March 11, 2020
Loftus TJ, Tighe PJ, Filiberto AC, et al. Artificial intelligence and surgical decision-making. JAMA Surg.
2019;155(2):148-158. doi:10.1001/jamasurg.2019.4917.
https://psnet.ahrq.gov/issue/artificial-intelligence-and-surgical-decision-making
Arti…
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psnet.ahrq.gov/node/867019/psn-pdf
October 23, 2024 - Reports on Hospital and ASC Performance.
October 23, 2024
Reports On Hospital And Asc Performance. Washington DC: The Leapfrog Group; September 2024.
https://psnet.ahrq.gov/issue/reports-hospital-and-asc-performance
Data collection and transparency are known to motivate change and drive improvement efforts. This se…
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psnet.ahrq.gov/node/43009/psn-pdf
January 07, 2015 - Improving the Emergency Department Discharge Process.
January 7, 2015
Boonyasai RT, Ijagbemi OM, Pham JC, et al. Rockville, MD: Agency for Healthcare Research and Quality;
December 2014. AHRQ Publication No. 14(15)-0067-EF.
https://psnet.ahrq.gov/issue/improving-emergency-department-discharge-process
This report a…
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psnet.ahrq.gov/node/42768/psn-pdf
November 27, 2013 - Findings and Lessons From the Improving Management
of Individuals With Complex Health Care Needs Through
Health IT Grant Initiative.
November 27, 2013
Rockville, MD: Agency for Healthcare Research and Quality; September 2013. AHRQ Publication No. 13-
0058-EF.
https://psnet.ahrq.gov/issue/findings-and-lesso…
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psnet.ahrq.gov/node/41222/psn-pdf
May 01, 2016 - Reducing Unnecessary Hospital Readmissions: The Role
of the Patient Safety Organization (PSO).
May 1, 2016
Agency for Healthcare Quality and Research.
https://psnet.ahrq.gov/issue/reducing-unnecessary-hospital-readmissions-role-patient-safety-organization-
pso
Patient safety organizations (PSO) present a unique o…
-
psnet.ahrq.gov/node/43525/psn-pdf
July 16, 2015 - Clinical handovers between prehospital and hospital
staff: literature review.
July 16, 2015
Wood K, Crouch R, Rowland E, et al. Clinical handovers between prehospital and hospital staff: literature
review. Emerg Med J. 2015;32(7):577-581. doi:10.1136/emermed-2013-203165.
https://psnet.ahrq.gov/issue/clinical-hando…
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psnet.ahrq.gov/node/50534/psn-pdf
October 16, 2019 - Strategies to reduce diagnostic errors: a systematic
review
October 16, 2019
Abimanyi-Ochom J, Mudiyanselage SB, Catchpool M, et al. Strategies to reduce diagnostic errors: a
systematic review. BMC Med Inform Decis Mak. 2019;19(1):174. doi:10.1186/s12911-019-0901-1.
https://psnet.ahrq.gov/issue/strategies-reduce-d…
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psnet.ahrq.gov/node/34036/psn-pdf
March 28, 2005 - National Center for Patient Safety Falls Toolkit 2004.
March 28, 2005
Department of Veterans Affairs (VA) National Center for Patient Safety
https://psnet.ahrq.gov/issue/national-center-patient-safety-falls-toolkit-2004
The National Center for Patient Safety created the Falls Toolkit to assist VA facilities in impl…
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psnet.ahrq.gov/node/43391/psn-pdf
July 30, 2014 - Special Issue on Patient Safety.
July 30, 2014
West J Nurs Res. 2014;36(7):851-946.
https://psnet.ahrq.gov/issue/special-issue-patient-safety-0
Articles in this special issue discuss errors of omission in nursing, the importance of situational awareness
during medication administration, how complexity of health ca…
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psnet.ahrq.gov/node/39486/psn-pdf
May 05, 2010 - Understanding handling of drug safety alerts: a
simulation study.
May 5, 2010
van der Sijs H, van Gelder T, Vulto A, et al. Understanding handling of drug safety alerts: a simulation
study. Int J Med Inform. 2010;79(5). doi:10.1016/j.ijmedinf.2010.01.008.
https://psnet.ahrq.gov/issue/understanding-handling-drug-sa…
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psnet.ahrq.gov/node/35913/psn-pdf
February 16, 2011 - Improving oversight of the graduate medical education
enterprise: one institution's strategies and tools.
February 16, 2011
Afrin LB, Arana GW, Medio FJ, et al. Improving Oversight of the Graduate Medical Education Enterprise:
One Institution???s Strategies and Tools. Academic Medicine. 2006;81(5).
doi:10.1097/01.…
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psnet.ahrq.gov/node/35720/psn-pdf
April 14, 2011 - A survey of factors affecting clinician acceptance of
clinical decision support.
April 14, 2011
Sittig DF, Krall MA, Dykstra RH, et al. A survey of factors affecting clinician acceptance of clinical decision
support. BMC Med Inform Decis Mak. 2006;6(1). doi:10.1186/1472-6947-6-6.
https://psnet.ahrq.gov/issue/surve…
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psnet.ahrq.gov/node/44977/psn-pdf
March 01, 2020 - Choosing a Patient Safety Organization
March 1, 2020
Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0030.
https://psnet.ahrq.gov/issue/choosing-patient-safety-organization
Patient safety organizations (PSOs) collect and analyze protected incident data from across the …
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psnet.ahrq.gov/node/44182/psn-pdf
November 03, 2015 - FDA cautions about dose confusion and medication
errors for antibacterial drug Zerbaxa (ceftolozane and
tazobactam).
November 3, 2015
Food and Drug Administration; FDA.
https://psnet.ahrq.gov/issue/fda-cautions-about-dose-confusion-and-medication-errors-antibacterial-drug-
zerbaxa
Dosing information on drug labe…
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psnet.ahrq.gov/node/46177/psn-pdf
March 09, 2018 - Diagnosis: Interpreting the Shadows.
March 9, 2018
Croskerry P, Cosby KS, Graber ML, Singh H. Boca Raton, FL: CRC Press; 2017. ISBN: 9781409432333.
https://psnet.ahrq.gov/issue/diagnosis-interpreting-shadows
Efforts to enhance the reliability of the diagnostic process must take various elements into consideration.
…