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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46715/psn-pdfMay 02, 2018 - Filling the gap: simulation-based crisis resource management training for emergency medicine residents. May 2, 2018 Parsons JR, Crichlow A, Ponnuru S, et al. Filling the gap: simulation-based crisis resource management training for emergency medicine residents. West J Emerg Med. 2018;19(1):205-210. doi:10.5811/wes… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45519/psn-pdfNovember 01, 2017 - Morbidity and mortality conferences: a narrative review of strategies to prioritize quality improvement. November 1, 2017 Giesbrecht V, Au S. Morbidity and Mortality Conferences: A Narrative Review of Strategies to Prioritize Quality Improvement. Jt Comm J Qual Patient Saf. 2016;42(11):516-527. doi:10.1016/S1553- … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46728/psn-pdfMarch 27, 2018 - Near-miss event analysis enhances the barcode medication administration process. March 27, 2018 Magee MC; Miller K; Patzek D; Madera C; Michalek C; Shetterly M. https://psnet.ahrq.gov/issue/near-miss-event-analysis-enhances-barcode-medication-administration- process Near misses provide unique opportunities to ide… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866317/psn-pdfJuly 17, 2024 - BONE break: a hot debrief tool to reduce second victim syndrome for nurses. July 17, 2024 Hess A, Flicek T, Watral AT, et al. BONE break: a hot debrief tool to reduce second victim syndrome for nurses. Jt Comm J Qual Patient Saf. 2024;50(9):673-677. doi:10.1016/j.jcjq.2024.05.005. https://psnet.ahrq.gov/issue/bone… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45256/psn-pdfJuly 01, 2017 - Applied use of safety event occurrence control charts of harm and non-harm events: a case study. July 1, 2017 Robinson SN, Neyens DM, Diller T. Applied Use of Safety Event Occurrence Control Charts of Harm and Non-Harm Events: A Case Study. Am J Med Qual. 2017;32(3):285-291. doi:10.1177/1062860616646197. https://p… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43353/psn-pdfJuly 16, 2014 - Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications. July 16, 2014 ISMP Medication Safety Alert! Acute care edition. July 3, 2014;19:1-3,5-6. https://psnet.ahrq.gov/issue/survey-suggests-possible-downward-trend-identifying-key-drugsdrug-classes- high-alert This … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/867180/psn-pdfNovember 20, 2024 - Medical error: using storytelling and reflection to impact error response factors in family medicine residents. November 20, 2024 Adkins S, Alta’any R, Brar K, et al. Medical error: using storytelling and reflection to impact error response factors in family medicine residents. J Med Educ Curric Dev. 2024;11:238212… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47890/psn-pdfJune 15, 2019 - Systems engineering and human factors support of a system of novel EHR-integrated tools to prevent harm in the hospital. June 15, 2019 Dalal A, Fuller T, Garabedian P, et al. Systems engineering and human factors support of a system of novel EHR-integrated tools to prevent harm in the hospital. J Am Med Inform Ass… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46862/psn-pdfFebruary 21, 2018 - Considering human factors and developing systems- thinking behaviours to ensure patient safety. February 21, 2018 Vosper H; Lim R; Knight C; et al; CIEHF Pharmaceutical Human Factors Special Interest Group. Clinical Pharmacist. 2018;10(2). https://psnet.ahrq.gov/issue/considering-human-factors-and-developing-syste… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/867694/psn-pdfMarch 05, 2025 - Hospital ward incidents through the eyes of nurses – a thick description on the appeal and deadlock of incident reporting systems. March 5, 2025 Tresfon J, van Winsen R, Brunsveld-Reinders AH, et al. Hospital ward incidents through the eyes of nurses - a thick description on the appeal and deadlock of incident rep… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60304/psn-pdfJanuary 01, 2021 - Patients' perspectives of diagnostic error: a qualitative study. May 6, 2020 Sacco AY, Self QR, Worswick EL, et al. Patients' perspectives of diagnostic error: a qualitative study. J Patient Saf. 2021;17(8):e1759-e1773. doi:10.1097/pts.0000000000000642. https://psnet.ahrq.gov/issue/patients-perspectives-diagnostic… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/862617/psn-pdfFebruary 14, 2024 - Risks to Medication Delivery Using Ambulatory Infusion Pumps – Design and Usability in Inpatient Settings. February 14, 2024 Dorset, UK: Health Services Safety Investigations Body; November 2023. https://psnet.ahrq.gov/issue/risks-medication-delivery-using-ambulatory-infusion-pumps-design-and- usability-inpatient … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/50892/psn-pdfFebruary 12, 2020 - Association of open communication and the emotional and behavioural impact of medical error on patients and families: state-wide cross-sectional survey. February 12, 2020 Prentice JC, Bell SK, Thomas EJ, et al. Association of open communication and the emotional and behavioural impact of medical error on patients … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36442/psn-pdfJuly 23, 2023 - TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety. July 23, 2023 Department of Health and Human Services, Agency for Healthcare Research and Quality, Department of Defense. https://psnet.ahrq.gov/issue/teamstepps-strategies-and-tools-enhance-performance-and-patient-safety Effective teamwo… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43957/psn-pdfJune 21, 2015 - Enhancing the effectiveness of team debriefings in medical simulation: more best practices. June 21, 2015 Lyons R, Lazzara EH, Benishek LE, et al. Enhancing the effectiveness of team debriefings in medical simulation: more best practices. Jt Comm J Qual Patient Saf. 2015;41(3):115-125. https://psnet.ahrq.gov/issue… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44851/psn-pdfMarch 16, 2016 - Understanding psychological safety in health care and education organizations: a comparative perspective. March 16, 2016 Edmondson AC, Higgins M, Singer SJ, et al. Understanding Psychological Safety in Health Care and Education Organizations: A Comparative Perspective. Res Hum Dev. 2016;13(1):65-83. doi:10.1080/15… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837896/psn-pdfJanuary 01, 2023 - Helping healthcare teams to debrief effectively: associations of debriefers' actions and participants' reflections during team debriefings. August 24, 2022 Kolbe M, Grande B, Lehmann-Willenbrock N, et al. Helping healthcare teams to debrief effectively: associations of debriefers’ actions and participants’ reflect… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47880/psn-pdfJune 18, 2019 - A multidisciplinary model for reviewing severe maternal morbidity cases and teaching residents patient safety principles. June 18, 2019 Ogunyemi D, Hage N, Kim SK, et al. A Multidisciplinary Model for Reviewing Severe Maternal Morbidity Cases and Teaching Residents Patient Safety Principles. Jt Comm J Qual Patient… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72684/psn-pdfJanuary 27, 2021 - National Partnership for Maternal Safety: consensus bundle on support after a severe maternal event. January 27, 2021 Morton CH, Hall MF, Shaefer SJM, et al. National Partnership for Maternal Safety: Consensus Bundle on Support After a Severe Maternal Event. J Obstet Gynecol Neonatal Nurs. 2021;50(1):88-101. doi:1… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73281/psn-pdfMay 19, 2021 - Measuring safety in older adult care homes: a scoping review of the international literature. May 19, 2021 Rand S, Smith N, Jones K, et al. Measuring safety in older adult care homes: a scoping review of the international literature. BMJ Open. 2021;11(3):e043206. doi:10.1136/bmjopen-2020-043206. https://psnet.ahrq…
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