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psnet.ahrq.gov/node/45445/psn-pdf
September 27, 2016 - Using Kotter's change model for implementing bedside
handoff: a quality improvement project.
September 27, 2016
Small A, Gist D, Souza D, et al. Using Kotter's Change Model for Implementing Bedside Handoff: A Quality
Improvement Project. J Nurs Care Qual. 2016;31(4):304-9. doi:10.1097/NCQ.0000000000000212.
https:/…
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psnet.ahrq.gov/node/39462/psn-pdf
April 21, 2010 - Comparing safety climate in naval aviation and hospitals:
implications for improving patient safety.
April 21, 2010
Singer SJ, Rosen AK, Zhao S, et al. Comparing safety climate in naval aviation and hospitals: implications
for improving patient safety. Health Care Manag Rev. 2010;35(2):134-146.
doi:10.1097/HMR.0b0…
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psnet.ahrq.gov/node/44047/psn-pdf
September 09, 2015 - Linking acknowledgement to action: closing the loop on
non-urgent, clinically significant test results in the
electronic health record.
September 9, 2015
Dalal A, Pesterev BM, Eibensteiner K, et al. Linking acknowledgement to action: closing the loop on non-
urgent, clinically significant test results in the elect…
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psnet.ahrq.gov/node/60844/psn-pdf
August 26, 2020 - Surgical errors happen, but are learners trained to
recover from them? A survey of North American surgical
residents and fellows.
August 26, 2020
Gabrysz-Forget F, Young M, Zahabi S, et al. Surgical errors happen, but are learners trained to recover
from them? A survey of North American surgical residents and fell…
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psnet.ahrq.gov/node/865816/psn-pdf
May 08, 2024 - The Safe Home Care Intervention Study: implementation
methods and effectiveness evaluation.
May 8, 2024
Sama SR, Quinn MM, Gore RJ, et al. The Safe Home Care Intervention Study: implementation methods
and effectiveness evaluation. J Appl Gerontol. 2024;43(11):1595-1604. doi:10.1177/07334648241246472.
https://psnet…
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psnet.ahrq.gov/node/850928/psn-pdf
June 21, 2023 - Patient safety perception within hospitals: an examination
of job type, handoffs and information exchange, and
hospital management support.
June 21, 2023
Ming Y, Meehan R. Patient safety perception within hospitals: an examination of job type, handoffs and
information exchange, and hospital management support. J P…
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psnet.ahrq.gov/node/42918/psn-pdf
February 05, 2014 - Ascension Health's demonstration of full disclosure
protocol for unexpected events during labor and delivery
shows promise.
February 5, 2014
Hendrich A, McCoy CK, Gale J, et al. Ascension health's demonstration of full disclosure protocol for
unexpected events during labor and delivery shows promise. Health Aff (M…
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psnet.ahrq.gov/node/853622/psn-pdf
January 01, 2024 - Enhancing patient safety: a national standard for cyber
resiliency in healthcare.
September 20, 2023
Samuelson-Kiraly C, Mitchell JI, Kingston D, et al. Enhancing patient safety: A national standard for cyber
resiliency in healthcare. Healthc Manage Forum. 2024;37(1):9-12. doi:10.1177/08404704231196138.
https://ps…
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psnet.ahrq.gov/node/866253/psn-pdf
July 10, 2024 - Identifying, understanding, and minimizing unconscious
cognitive biases in perioperative crisis management: a
narrative review.
July 10, 2024
Yan L, Karamchandani K, Gaiser RR, et al. Identifying, understanding, and minimizing unconscious
cognitive biases in perioperative crisis management: a narrative review. Ane…
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psnet.ahrq.gov/node/60054/psn-pdf
March 18, 2020 - Ensuring successful implementation of communication-
and-resolution programmes.
March 18, 2020
Mello MM, Roche S, Greenberg Y, et al. Ensuring successful implementation of communication-and-
resolution programmes. BMJ Qual Saf. 2020;29(11):895-904. doi:10.1136/bmjqs-2019-010296.
https://psnet.ahrq.gov/issue/ensuri…
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psnet.ahrq.gov/node/47522/psn-pdf
January 01, 2021 - Examining medical office owners and clinicians
perceptions on patient safety climate.
November 7, 2018
Mazurenko O, Richter J, Kazley AS, et al. Examining Medical Office Owners and Clinicians Perceptions on
Patient Safety Climate. J Patient Saf. 2021;17(8):e1537-e1545. doi:10.1097/PTS.0000000000000540.
https://psn…
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psnet.ahrq.gov/node/73215/psn-pdf
May 05, 2021 - To err is system: a comparison of methodologies for the
investigation of adverse outcomes in healthcare.
May 5, 2021
Isherwood P, Waterson P. To err is system: a comparison of methodologies for the investigation of adverse
outcomes in healthcare. J Patient Saf Risk Manag. 2021;26(2):64-73. doi:10.1177/2516043521990…
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psnet.ahrq.gov/node/836807/psn-pdf
March 30, 2022 - Preventing delayed and missed care by applying artificial
intelligence to trigger radiology imaging follow-up.
March 30, 2022
Domingo J, Galal G, Huang J. Preventing delayed and missed care by applying artificial intelligence to
trigger radiology imaging follow-up. NEJM Catal Innov Care Deliv. 2022;3(4).
https://p…
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psnet.ahrq.gov/node/45014/psn-pdf
July 18, 2016 - Improving patient safety through simulation training in
anesthesiology: where are we?
July 18, 2016
Green M, Tariq R, Green P. Improving Patient Safety through Simulation Training in Anesthesiology:
Where Are We? Anesthesiol Res Pract. 2016;2016:4237523. doi:10.1155/2016/4237523.
https://psnet.ahrq.gov/issue/impro…
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psnet.ahrq.gov/node/837731/psn-pdf
July 27, 2022 - Predictors and outcomes of patient safety culture: a
cross-sectional comparative study.
July 27, 2022
Mrayyan MT. Predictors and outcomes of patient safety culture: a cross-sectional comparative study. BMJ
Open Qual. 2022;11(3):e001889. doi:10.1136/bmjoq-2022-001889.
https://psnet.ahrq.gov/issue/predictors-and-out…
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psnet.ahrq.gov/node/837331/psn-pdf
June 08, 2022 - Can a targeted educational approach improve situational
awareness in paramedicine during 911 emergency calls?
June 8, 2022
Hunter J, Porter M, Cody P, et al. Can a targeted educational approach improve situational awareness in
paramedicine during 911 emergency calls? Int Emerg Nurs. 2022;63:101174.
doi:10.1016/j.i…
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psnet.ahrq.gov/node/866639/psn-pdf
September 04, 2024 - Relationship between patient safety culture and patient
experience in hospital settings: a scoping review.
September 4, 2024
Alabdaly A, Hinchcliff R, Debono D, et al. Relationship between patient safety culture and patient
experience in hospital settings: a scoping review. BMC Health Serv Res. 2024;24(1):906.
doi…
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psnet.ahrq.gov/node/45734/psn-pdf
January 23, 2017 - Inappropriate opioid dosing and prescribing for children:
an unintended consequence of the clinical pain score?
January 23, 2017
Voepel-Lewis T, Malviya S, Tait AR. Inappropriate Opioid Dosing and Prescribing for Children: An
Unintended Consequence of the Clinical Pain Score? JAMA Pediatr. 2017;171(1):5-6.
doi:10.…
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psnet.ahrq.gov/node/837147/psn-pdf
May 18, 2022 - Patient safety in home care: a multicenter cross-sectional
study about medication errors and medication
management of nurses.
May 18, 2022
Strube?Lahmann S, Müller?Werdan U, Klingelhöfer?Noe J, et al. Patient safety in home care: A multicenter
cross?sectional study about medication errors and medication management…
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psnet.ahrq.gov/node/837677/psn-pdf
July 13, 2022 - Multiple Failures in Test Results Follow-up for a Patient
Diagnosed with Prostate Cancer at the Hampton VA
Medical Center in Virginia.
July 13, 2022
Washington, DC: VA Office of the Inspector General; June 28, 2022. Report No 21-03349-186.
https://psnet.ahrq.gov/issue/multiple-failures-test-results-follow-patient-…