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psnet.ahrq.gov/node/842763/psn-pdf
January 18, 2023 - Implementation of peer messengers to deliver feedback:
an observational study to promote professionalism in
nursing.
January 18, 2023
Baldwin CA, Hanrahan K, Edmonds SW, et al. Implementation of peer messengers to deliver feedback: an
observational study to promote professionalism in nursing. Jt Comm J Qual Patien…
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psnet.ahrq.gov/node/36003/psn-pdf
March 28, 2011 - The "To Err Is Human Report" and the patient safety
literature.
March 28, 2011
Stelfox HT, Palmisani S, Scurlock C, et al. The "To Err is Human" report and the patient safety literature.
Qual Saf Health Care. 2006;15(3):174-8.
https://psnet.ahrq.gov/issue/err-human-report-and-patient-safety-literature
This study …
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psnet.ahrq.gov/node/35436/psn-pdf
September 15, 2009 - Hospital nurse staffing and patient mortality, emotional
exhaustion, and job dissatisfaction.
September 15, 2009
Halm M, Peterson M, Kandels M, et al. Hospital nurse staffing and patient mortality, emotional exhaustion,
and job dissatisfaction. Clin Nurse Spec. 2005;19(5):241-254.
https://psnet.ahrq.gov/issue/hosp…
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psnet.ahrq.gov/node/40119/psn-pdf
January 05, 2011 - Effects of learning climate and registered nurse staffing
on medication errors.
January 5, 2011
Chang YK, Mark BA. Effects of Learning Climate and Registered Nurse Staffing on Medication Errors. Nurs
Res. 2010;60(1). doi:10.1097/nnr.0b013e3181ff73cc.
https://psnet.ahrq.gov/issue/effects-learning-climate-and-regist…
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psnet.ahrq.gov/node/72627/psn-pdf
January 13, 2021 - Creating a framework to integrate residency program and
medical center approaches to quality improvement and
patient safety training
January 13, 2021
Chen A, Wolpaw BJ, Vande Vusse LK, et al. Creating a framework to integrate residency program and
medical center approaches to quality improvement and patient safety…
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psnet.ahrq.gov/node/40441/psn-pdf
July 02, 2014 - A novel approach to increase residents' involvement in
reporting adverse events.
July 2, 2014
Scott DR, Weimer M, English C, et al. A novel approach to increase residents' involvement in reporting
adverse events. Acad Med. 2011;86(6):742-746. doi:10.1097/ACM.0b013e318217e12a.
https://psnet.ahrq.gov/issue/novel-app…
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psnet.ahrq.gov/node/37471/psn-pdf
February 17, 2011 - Delayed time to defibrillation after in-hospital cardiac
arrest.
February 17, 2011
Chan PS, Krumholz HM, Nichol G, et al. Delayed time to defibrillation after in-hospital cardiac arrest. N
Engl J Med. 2008;358(1):9-17. doi:10.1056/NEJMoa0706467.
https://psnet.ahrq.gov/issue/delayed-time-defibrillation-after-hospit…
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psnet.ahrq.gov/node/841141/psn-pdf
December 07, 2022 - Urgent referrals from primary care to dermatology for
lesions suspicious for skin cancer: patterns, outcomes,
and need for systems improvement.
December 7, 2022
Pagani K, Lukac D, Olbricht SM, et al. Urgent referrals from primary care to dermatology for lesions
suspicious for skin cancer: patterns, outcomes, and n…
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psnet.ahrq.gov/node/44552/psn-pdf
June 21, 2016 - Reducing diagnostic errors—why now?
June 21, 2016
Khullar D, Jha AK, Jena AB. Reducing diagnostic errors--why now? N Engl J Med. 2015;373(26):2491-
2493. doi:10.1056/NEJMp1508044.
https://psnet.ahrq.gov/issue/reducing-diagnostic-errors-why-now
Diagnostic error has recently garnered attention as a patient safety pr…
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psnet.ahrq.gov/node/853429/psn-pdf
September 13, 2023 - Multifaceted intervention to improve patient safety
incident reporting in intensive care units.
September 13, 2023
Griffeth EM, Gajic O, Schueler N, et al. Multifaceted intervention to improve patient safety incident reporting
in intensive care units. J Patient Saf. 2023;19(7):422-428. doi:10.1097/pts.0000000000001…
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psnet.ahrq.gov/node/37871/psn-pdf
January 06, 2017 - A controlled trial of a rapid response system in an
academic medical center.
January 6, 2017
Rothschild JM, Woolf S, Finn KM, et al. A controlled trial of a rapid response system in an academic
medical center. Jt Comm J Qual Patient Saf. 2008;34(7):417-25, 365.
https://psnet.ahrq.gov/issue/controlled-trial-rapid-r…
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psnet.ahrq.gov/node/844769/psn-pdf
January 01, 2020 - Failure to administer recommended chemotherapy:
acceptable variation or cancer care quality blind spot?
September 18, 2019
Ellis RJ, Schlick CJR, Feinglass J, et al. Failure to administer recommended chemotherapy: acceptable
variation or cancer care quality blind spot? BMJ Qual Saf. 2020;29(2):103-112. doi:10.1136/…
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psnet.ahrq.gov/node/40859/psn-pdf
October 19, 2011 - Why patient summaries in electronic health records do
not provide the cognitive support necessary for nurses'
handoffs on medical and surgical units: insights from
interviews and observations.
October 19, 2011
Staggers N, Clark L, Blaz JW, et al. Why patient summaries in electronic health records do not provide th…
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psnet.ahrq.gov/node/36457/psn-pdf
May 27, 2011 - Controversies surrounding use of order sets for clinical
decision support in computerized provider order entry.
May 27, 2011
Bobb AM, Payne TH, Gross PA. Viewpoint: controversies surrounding use of order sets for clinical decision
support in computerized provider order entry. J Am Med Inform Assoc. 2007;14(1):41-7.…
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psnet.ahrq.gov/node/60524/psn-pdf
May 27, 2020 - Varying rates of patient identity verification when using
computerized provider order entry.
May 27, 2020
Fortman E, Hettinger AZ, Howe JL, et al. Varying rates of patient identity verification when using
computerized provider order entry. J Am Med Info Assoc. 2020;27(6):924-928. doi:10.1093/jamia/ocaa047.
https:/…
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psnet.ahrq.gov/node/46009/psn-pdf
September 13, 2017 - Use of standard risk screening and assessment forms to
prevent harm to older people in Australian hospitals: a
mixed methods study.
September 13, 2017
Redley B, Raggatt M. Use of standard risk screening and assessment forms to prevent harm to older
people in Australian hospitals: a mixed methods study. BMJ Qual Sa…
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psnet.ahrq.gov/node/35907/psn-pdf
October 03, 2017 - Transparent and open discussion of errors does not
increase malpractice risk in trauma patients.
October 3, 2017
Stewart RM, Corneille MG, Johnston J, et al. Transparent and open discussion of errors does not increase
malpractice risk in trauma patients. Ann Surg. 2006;243(5):645-9; discussion 649-51.
https://psne…
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psnet.ahrq.gov/node/37655/psn-pdf
September 24, 2010 - Reducing anticoagulant medication adverse events and
avoidable patient harm.
September 24, 2010
Jennings HR, Miller EC, Williams TS, et al. Reducing anticoagulant medication adverse vents and
avoidable patient harm. Jt Comm J Qual Patient Saf. 2008;34(4):196-200.
https://psnet.ahrq.gov/issue/reducing-anticoagulant…
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psnet.ahrq.gov/node/42419/psn-pdf
July 17, 2013 - Health IT Patient Safety Action and Surveillance Plan.
July 17, 2013
Washington, DC: Office of the National Coordinator for Health Information Technology; July 2, 2013.
https://psnet.ahrq.gov/issue/health-it-patient-safety-action-and-surveillance-plan
This report from the Department of Health and Human Services (HH…
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psnet.ahrq.gov/node/44127/psn-pdf
September 28, 2017 - Overkill: An avalanche of unnecessary medical care is
harming patients physically and financially. What can we
do about it?
September 28, 2017
Gawande A. The New Yorker. May 2015
https://psnet.ahrq.gov/issue/overkill-avalanche-unnecessary-medical-care-harming-patients-physically-and-
financially-what
The overuse…