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psnet.ahrq.gov/node/50802/psn-pdf
January 15, 2020 - Use of error management theory to quantify and
characterize residents' error recovery strategies.
January 15, 2020
Pugh CM, Law KE, Cohen ER, et al. Use of error management theory to quantify and characterize
residents’ error recovery strategies. Am J Surg. 2020;219(2):214-220. doi:10.1016/j.amjsurg.2019.11.013.
h…
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psnet.ahrq.gov/node/72523/psn-pdf
December 02, 2020 - Clinical decision support improves the appropriateness of
laboratory test ordering in primary care without
increasing diagnostic error: the ELMO cluster randomized
trial.
December 2, 2020
Delvaux N, Piessens V, Burghgraeve TD, et al. Clinical decision support improves the appropriateness of
laboratory test orderi…
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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/73169/psn-pdf
April 21, 2021 - Application of emergency preparedness principles to a
pharmacy department’s approach to a “black swan”
event: the COVID-19 pandemic.
April 21, 2021
Waldron KM, Schenkat DH, Rao KV, et al. Application of emergency preparedness principles to a
pharmacy department’s approach to a “black swan” event: the COVID-19 pand…
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psnet.ahrq.gov/node/837762/psn-pdf
August 03, 2022 - A scoping review of real-time automated clinical
deterioration alerts and evidence of impacts on
hospitalised patient outcomes.
August 3, 2022
Blythe R, Parsons R, White NM, et al. A scoping review of real-time automated clinical deterioration alerts
and evidence of impacts on hospitalised patient outcomes. BMJ Qu…
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psnet.ahrq.gov/node/847054/psn-pdf
April 05, 2023 - Patient generated research priorities to improve
diagnostic safety: a systematic prioritization exercise.
April 5, 2023
Zwaan L, Smith KM, Giardina TD, et al. Patient generated research priorities to improve diagnostic safety:
a systematic prioritization exercise. Patient Educ Couns. 2023;110:107650.
doi:10.1016/j…
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psnet.ahrq.gov/node/40805/psn-pdf
July 19, 2016 - Improving America's Hospitals: The Joint Commission's
Annual Report on Quality and Safety 2011.
July 19, 2016
Oakbrook Terrace, IL: The Joint Commission; September 2011.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-
safety-2011
This report emphasizes perfor…
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psnet.ahrq.gov/node/47254/psn-pdf
September 19, 2018 - Understanding the knowledge gaps in whistleblowing and
speaking up in health care: narrative reviews of the
research literature and formal inquiries, a legal analysis
and stakeholder interviews.
September 19, 2018
Mannion R, Blenkinsopp J, Powell M, et al. Southampton (UK): NIHR Journals Library; August 2018.…
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psnet.ahrq.gov/node/47388/psn-pdf
March 13, 2019 - Artificial intelligence systems for complex decision-
making in acute care medicine: a review.
March 13, 2019
Lynn LA. Artificial intelligence systems for complex decision-making in acute care medicine: a review.
Patient Saf Surg. 2019;13:6. doi:10.1186/s13037-019-0188-2.
https://psnet.ahrq.gov/issue/artificial-in…
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psnet.ahrq.gov/node/47240/psn-pdf
March 06, 2019 - Improving detection of intraoperative medical errors
(iMEs) and intraoperative adverse events (iAEs) and their
contribution to postoperative outcomes.
March 6, 2019
Chen Q, Rosen AK, Amirfarzan H, et al. Improving detection of intraoperative medical errors (iMEs) and
intraoperative adverse events (iAEs) and their …
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psnet.ahrq.gov/node/838321/psn-pdf
October 12, 2022 - Meeting the Moment: Addressing Barriers and Facilitating
Clinical Adoption of Artificial Intelligence in Medical
Diagnosis.
October 12, 2022
Adler-Milstein J, Aggarwal N, Ahmed M, et al. NAM Perspectives. Washington DC: National Academy of
Medicine; 2022.
https://psnet.ahrq.gov/issue/meeting-moment-addressing-bar…
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psnet.ahrq.gov/node/851457/psn-pdf
July 19, 2023 - Root causes and preventability of unintentionally retained
foreign objects after surgery: a national expert survey
from Switzerland.
July 19, 2023
Schwappach DLB, Pfeiffer Y. Root causes and preventability of unintentionally retained foreign objects
after surgery: a national expert survey from Switzerland. Patient…
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psnet.ahrq.gov/node/46765/psn-pdf
April 04, 2018 - Advancing perinatal patient safety through application of
safety science principles using health IT.
April 4, 2018
Webb J, Sorensen A, Sommerness SA, et al. Advancing perinatal patient safety through application of
safety science principles using health IT. BMC Med Inform Decis Mak. 2017;17(1):176.
doi:10.1186/s12…
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psnet.ahrq.gov/node/854627/psn-pdf
October 18, 2023 - Implementing strategies to prevent home medication
administration errors in children with medical complexity.
October 18, 2023
Shaikh U, Kim JM, Yin SH. Implementing strategies to prevent home medication administration errors in
children with medical complexity. Clin Pediatr (Phila). 2023;20(18):6788. doi:10.1177/0…
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psnet.ahrq.gov/node/60526/psn-pdf
May 27, 2020 - A qualitative content analysis of retained surgical items:
learning from root cause analysis investigations.
May 27, 2020
Hibbert PD, Thomas MJW, Deakin A, et al. A qualitative content analysis of retained surgical items:
learning from root cause analysis investigations. Int J Qual Health Care. 2020;32(3):184-189.
…
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psnet.ahrq.gov/node/38309/psn-pdf
December 23, 2016 - Safely implementing health information and converging
technologies.
December 23, 2016
Safely implementing health information and converging technologies. Sentinel event alert. 2008;(42):1-4.
https://psnet.ahrq.gov/issue/safely-implementing-health-information-and-converging-technologies
As health information techno…
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psnet.ahrq.gov/node/837851/psn-pdf
August 17, 2022 - Medication errors in intensive care units: an umbrella
review of control measures.
August 17, 2022
Dionisi S, Giannetta N, Liquori G, et al. Medication errors in intensive care units: an umbrella review of
control measures. Healthcare (Basel). 2022;10(7):1221. doi:10.3390/healthcare10071221.
https://psnet.ahrq.gov…
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www.ahrq.gov/ncepcr/reports/2024-annual-report/appendix-c.html
May 01, 2024 - Foster Care
S8: Understanding How Nurse Practitioners Increase Access to Primary Care
S9: Using Integrated … Study (U18) PIs: Adonis K Hijaz; Goutham Rao Organization: University Hospitals of Cleveland Uses an integrated
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm3.html
October 01, 2014 - Instead, programs managing complex comorbid conditions require an integrated delivery system that incorporates … In addition, Medicaid beneficiaries in long-term care facilities should be receiving integrated care
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www.ahrq.gov/sites/default/files/2025-05/blocker-report.pdf
January 01, 2025 - We recognize that, in order for resiliency to be fully integrated into healthcare, we
must demonstrate