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psnet.ahrq.gov/issue/coaching-improve-quality-communication-during-briefings-and-debriefings
March 02, 2022 - Study
Coaching to improve the quality of communication during briefings and debriefings.
Citation Text:
Kleiner C, Link T, Maynard T, et al. Coaching to improve the quality of communication during briefings and debriefings. AORN J. 2014;100(4):358-68. doi:10.1016/j.aorn.2014.03.012.
Co…
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psnet.ahrq.gov/issue/studying-critical-values-adverse-event-identification-following-critical-laboratory-values
September 01, 2018 - Study
Studying critical values: adverse event identification following a critical laboratory values study at the Ohio State University Medical Center.
Citation Text:
Jenkins JJ, Crawford M, Bissell MG. Studying critical values: adverse event identification following a critical laborato…
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psnet.ahrq.gov/issue/spreading-human-factors-expertise-healthcare-untangling-knots-people-and-systems
May 01, 2024 - Commentary
Spreading human factors expertise in healthcare: untangling the knots in people and systems.
Citation Text:
Catchpole K. Spreading human factors expertise in healthcare: untangling the knots in people and systems. BMJ Qual Saf. 2013;22(10):793-7. doi:10.1136/bmjqs-2013-002036…
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psnet.ahrq.gov/issue/critical-phase-distractions-anaesthesia-and-sterile-cockpit-concept
April 24, 2018 - Study
Critical phase distractions in anaesthesia and the sterile cockpit concept.
Citation Text:
Broom MA, Capek AL, Carachi P, et al. Critical phase distractions in anaesthesia and the sterile cockpit concept. Anaesthesia. 2011;66(3):175-179. doi:10.1111/j.1365-2044.2011.06623.x.
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psnet.ahrq.gov/issue/physical-and-verbal-violence-against-health-care-workers
December 23, 2016 - Sentinel Event Alerts
Physical and verbal violence against health care workers.
Citation Text:
Physical and verbal violence against health care workers. Sentinel Event Alert. 2018;59:1-9 (revised June 18, 2021).
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psnet.ahrq.gov/issue/ahrq-national-scorecard-hospital-acquired-conditions-updated-baseline-rates-and-preliminary
October 23, 2019 - Book/Report
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2016.
Citation Text:
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2016. Rockville, MD: Agency for Healthc…
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psnet.ahrq.gov/issue/task-uncertainty-and-communication-during-nursing-shift-handovers
August 20, 2018 - Study
Task uncertainty and communication during nursing shift handovers.
Citation Text:
Mayor E, Bangerter A, Aribot M. Task uncertainty and communication during nursing shift handovers. J Adv Nurs. 2012;68(9):1956-66. doi:10.1111/j.1365-2648.2011.05880.x.
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psnet.ahrq.gov/issue/nursing-perception-impact-medication-carts-patient-safety-and-ergonomics-teaching-health-care
May 29, 2014 - Study
Nursing perception of the impact of medication carts on patient safety and ergonomics in a teaching health care center.
Citation Text:
Rochais E, Atkinson S, Bussières J-F. Nursing perception of the impact of medication carts on patient safety and ergonomics in a teaching health ca…
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psnet.ahrq.gov/issue/automated-drug-dispensing-system-reduces-medication-errors-intensive-care-setting
April 08, 2009 - Study
Automated drug dispensing system reduces medication errors in an intensive care setting.
Citation Text:
Chapuis C, Roustit M, Bal G, et al. Automated drug dispensing system reduces medication errors in an intensive care setting. Crit Care Med. 2010;38(12):2275-2281. doi:10.1097/C…
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psnet.ahrq.gov/issue/ems-helicopter-crashes-what-influences-fatal-outcome
September 23, 2020 - Study
EMS helicopter crashes: what influences fatal outcome?
Citation Text:
Baker SP, Grabowski JG, Dodd RS, et al. EMS helicopter crashes: what influences fatal outcome? Ann Emerg Med. 2006;47(4):351-356.
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psnet.ahrq.gov/issue/electronic-health-record-programs-participation-has-increased-action-needed-achieve-goals
September 07, 2016 - Book/Report
Electronic Health Record Programs: Participation Has Increased, but Action Needed to Achieve Goals, Including Improved Quality of Care.
Citation Text:
Electronic Health Record Programs: Participation Has Increased, but Action Needed to Achieve Goals, Including Improved Quali…
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psnet.ahrq.gov/issue/failure-report-poor-care-breach-moral-and-professional-expectation
March 05, 2025 - Commentary
Failure to report poor care as a breach of moral and professional expectation.
Citation Text:
Ion R, Olivier S, Darbyshire P. Failure to report poor care as a breach of moral and professional expectation. Nurs Inq. 2019;26(3):e12299. doi:10.1111/nin.12299.
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psnet.ahrq.gov/issue/risk-factors-missed-colorectal-lesions-after-colonoscopy
March 25, 2020 - Study
Risk factors of missed colorectal lesions after colonoscopy.
Citation Text:
Lee J, Park SW, Kim YS, et al. Risk factors of missed colorectal lesions after colonoscopy. Medicine (Baltimore). 2017;96(27):e7468. doi:10.1097/MD.0000000000007468.
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psnet.ahrq.gov/issue/evaluation-information-transfer-through-continuum-surgical-care-feasibility-study
December 21, 2014 - Study
An evaluation of information transfer through the continuum of surgical care: a feasibility study.
Citation Text:
Nagpal K, Vats A, Ahmed K, et al. An evaluation of information transfer through the continuum of surgical care: a feasibility study. Ann Surg. 2010;252(2):402-7. doi:1…
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psnet.ahrq.gov/primer/alert-fatigue
March 15, 2025 - phenomenon occurs because of the sheer number of alerts, and it is compounded by the fact that the vast majority … Clinicians generally override the vast majority of CPOE warnings, even "critical" alerts that warn
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psnet.ahrq.gov/issue/why-simulation-matters-systematic-review-medical-errors-occurring-during-simulated-health
September 25, 2019 - Citation
Related Resources From the Same Author(s)
Debunking the myth that the majority
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psnet.ahrq.gov/curated-library/diagnostic-error
September 01, 2025 - The majority of the diagnostic errors resulted in some form of clinical impact, including short-term … Missed or delayed diagnoses accounted for 21% of 55,377 claims analyzed, and the majority of these cases … Investigators found that three groups of diagnoses accounted for the majority of closed claims and high-severity
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psnet.ahrq.gov/node/33798/psn-pdf
January 01, 2015 - ineffective strategy for preventing further patient safety mishaps, particularly
considering that the majority … The majority of respondents, in all groups,
endorsed punitive measures such as fines, suspensions, or
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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - High-Risk Pregnancy Program links clinicians and
patients across the state with UAMS, where the vast majority … Pregnancy Program links patients and clinicians across the state with the medical center,
where the vast majority … The majority of
referrals continue to be managed locally, but patients with abnormal findings may be … access to consultations: Since the implementation of the High-Risk Pregnancy
Program in 2003, the vast majority … Renewing annually, the program contract dedicates
the majority of funding toward the telemedicine infrastructure
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psnet.ahrq.gov/node/33853/psn-pdf
March 01, 2018 - But it is
disappointing that in the majority of hospitals there has been no change, and some hospitals … A majority of nurses say that they and other staff feel like their mistakes are held against them
and … RW: The majority of nurses in hospitals are working with and through technology.