-
psnet.ahrq.gov/node/60707/psn-pdf
July 22, 2020 - The devil is in the detail: how a closed-loop
documentation system for IV infusion administration
contributes to and compromises patient safety.
July 22, 2020
Furniss D, Dean Franklin B, Blandford A. The devil is in the detail: how a closed-loop documentation
system for IV infusion administration contributes to an…
-
psnet.ahrq.gov/node/47853/psn-pdf
April 10, 2019 - Does a unit shift report "blackout" period improve patient
safety?
April 10, 2019
Olmstead J. Does a unit shift report "blackout" period improve patient safety? Nurs Manage. 2019;50(3):8-
10. doi:10.1097/01.NUMA.0000553500.85897.51.
https://psnet.ahrq.gov/issue/does-unit-shift-report-blackout-period-improve-patien…
-
psnet.ahrq.gov/node/849610/psn-pdf
May 31, 2023 - Implementation of ED I-PASS as a standardized handoff
tool in the pediatric emergency department.
May 31, 2023
Yanni E, Calaman S, Wiener E, et al. Implementation of ED I-PASS as a standardized handoff tool in the
pediatric emergency department. J Healthc Qual. 2023;45(3):140-147.
doi:10.1097/jhq.0000000000000374.…
-
psnet.ahrq.gov/node/45106/psn-pdf
August 16, 2017 - The 'go-between' study: a simulation study comparing the
'Traffic Lights' and 'SBAR' tools as a means of
communication between anaesthetic staff.
August 16, 2017
MacDougall-Davis SR, Kettley L, Cook TM. The 'go-between' study: a simulation study comparing the
'Traffic Lights' and 'SBAR' tools as a means of communi…
-
psnet.ahrq.gov/node/47193/psn-pdf
September 05, 2018 - Situation, background, assessment, recommendation
(SBAR) communication tool for handoff in health care- a
narrative review.
September 5, 2018
Shahid S, Thomas S. Situation, background, assessment, recommendation (SBAR) communication tool for
handoff in health care; a narrative review. Saf Health. 2018;4(7). doi:10…
-
psnet.ahrq.gov/node/36280/psn-pdf
May 27, 2011 - Types of unintended consequences related to
computerized provider order entry.
May 27, 2011
Campbell EM, Sittig DF, Ash JS, et al. Types of unintended consequences related to computerized
provider order entry. J Am Med Inform Assoc. 2006;13(5):547-56.
https://psnet.ahrq.gov/issue/types-unintended-consequences-rela…
-
psnet.ahrq.gov/node/47273/psn-pdf
September 05, 2018 - Natural language processing and its implications for the
future of medication safety: a narrative review of recent
advances and challenges.
September 5, 2018
Wong A, Plasek JM, Montecalvo SP, et al. Natural Language Processing and Its Implications for the Future
of Medication Safety: A Narrative Review of Recent A…
-
psnet.ahrq.gov/node/47395/psn-pdf
October 10, 2018 - Using EMR-enabled computerized decision support
systems to reduce prescribing of potentially inappropriate
medications: a narrative review.
October 10, 2018
Scott IA, Pillans PI, Barras M, et al. Using EMR-enabled computerized decision support systems to reduce
prescribing of potentially inappropriate medications:…
-
psnet.ahrq.gov/node/47515/psn-pdf
February 25, 2019 - Blood sampling guidelines with focus on patient safety
and identification—a review.
February 25, 2019
Cornes M, Ibarz M, Ivanov H, et al. Blood sampling guidelines with focus on patient safety and identification
- a review. Diagnosis (Berl). 2019;6(1):33-37. doi:10.1515/dx-2018-0042.
https://psnet.ahrq.gov/issue/b…
-
psnet.ahrq.gov/node/60792/psn-pdf
August 12, 2020 - Nurse workarounds in the electronic health record: an
integrative review.
August 12, 2020
Fraczkowski D, Matson J, Lopez KD. Nurse workarounds in the electronic health record: an integrative
review. J Am Med Inform Assoc. 2020;27(7):1149-1165. doi:10.1093/jamia/ocaa050.
https://psnet.ahrq.gov/issue/nurse-workaroun…
-
psnet.ahrq.gov/node/858170/psn-pdf
December 13, 2023 - Unsafe care in residential settings for older adults. A
content analysis of accreditation reports.
December 13, 2023
Hibbert PD, Ash R, Molloy CJ, et al. Unsafe care in residential settings for older adults: a content analysis
of accreditation reports. Int J Qual Health Care. 2023;35(4):mzad085. doi:10.1093/intqhc/…
-
psnet.ahrq.gov/node/61120/psn-pdf
November 11, 2020 - Application of human factors methods to understand
missed follow-up of abnormal test results.
November 11, 2020
Rogith D, Satterly T, Singh H, et al. Application of human factors methods to understand missed follow-up
of abnormal test results. Appl Clin Inform. 2020;11(05):692-698. doi:10.1055/s-0040-1716537.
http…
-
psnet.ahrq.gov/issue/sorry-works
November 15, 2024 - Multi-use Website
Sorry Works!
Save
Save to your library
Print
Download PDF
Share
Facebook
Twitter
Linkedin
Copy URL
March 17, 2011
Sorry Works! supports a full-disclosure approach to medical errors. They encourage…
-
psnet.ahrq.gov/node/866733/psn-pdf
September 18, 2024 - A coproduced family reporting intervention to improve
safety surveillance and reduce disparities.
September 18, 2024
Khan A, Baird JD, Mauskar S, et al. A coproduced family reporting intervention to improve safety
surveillance and reduce disparities. Pediatrics. 2024;154(4):e2023065245. doi:10.1542/peds.2023-065245…
-
psnet.ahrq.gov/node/44805/psn-pdf
January 27, 2016 - NHS Safety Thermometer Reports.
January 27, 2016
Leeds, UK: Clinical Support Audit Unit, Health and Social Care Information Centre. 2012-2017.
https://psnet.ahrq.gov/issue/nhs-safety-thermometer-report-patient-harms-and-harm-free-care-november-
2014-november-2015
The NHS Safety Thermometer was a tool developed by …
-
psnet.ahrq.gov/node/857581/psn-pdf
January 01, 2025 - Medicare and Medicaid Programs and the Children’s
Health Insurance Program; Hospital Inpatient Prospective
Payment Systems for Acute Care Hospitals and the Long-
Term Care Hospital Prospective Payment System and
Policy Changes and Fiscal Year 2025 Rates; Quality
Programs Requirements; and Other Policy Changes.
Au…
-
psnet.ahrq.gov/node/72575/psn-pdf
January 01, 2021 - Missing the near miss: recognizing valuable learning
opportunities in radiation oncology.
December 16, 2020
Kundu P, Jung OS, Valle LF, et al. Missing the near miss: recognizing valuable learning opportunities in
radiation oncology. Pract Radiat Oncol. 2021;11(3):e256-e262. doi:10.1016/j.prro.2020.09.007.
https://…
-
psnet.ahrq.gov/node/36604/psn-pdf
June 04, 2024 - Adverse Health Events in Minnesota: Annual Reports.
June 4, 2024
St Paul, MN: Minnesota Department of Health.
https://psnet.ahrq.gov/issue/adverse-health-events-minnesota-15th-annual-public-report
The National Quality Forum has defined 29 never events—patient safety problems that should never occur,
such as wrong-…
-
psnet.ahrq.gov/node/35551/psn-pdf
June 08, 2010 - Validity of unplanned admission to an intensive care unit
as a measure of patient safety in surgical patients.
June 8, 2010
Haller G, Myles PS, Wolfe R, et al. Validity of unplanned admission to an intensive care unit as a measure
of patient safety in surgical patients. Anesthesiology. 2005;103(6):1121-1129.
https…
-
psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
January 01, 2016 - In Conversation With… Mark L. Graber, MD
January 1, 2016
Also Read an Essay
Citation Text:
In Conversation With… Mark L. Graber, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
…