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psnet.ahrq.gov/node/40346/psn-pdf
November 26, 2014 - Inability of providers to predict unplanned readmissions.
November 26, 2014
Allaudeen N, Schnipper JL, Orav J, et al. Inability of providers to predict unplanned readmissions. J Gen
Intern Med. 2011;26(7):771-6. doi:10.1007/s11606-011-1663-3.
https://psnet.ahrq.gov/issue/inability-providers-predict-unplanned-readmi…
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psnet.ahrq.gov/node/36065/psn-pdf
May 27, 2011 - Passing the "Yo' Mama" test.
May 27, 2011
Blair R. Passing the "Yo' Mama" test. Atlanta healthcare organization follows the beat of a different
drummer in achieving 100 percent CPOE adoption. Health Manag Technol. 2006;27(6):14, 16, 18.
https://psnet.ahrq.gov/issue/passing-yo-mama-test
This article discusses how a…
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psnet.ahrq.gov/node/35441/psn-pdf
September 18, 2009 - Bridging the communication gap in the operating room
with medical team training.
September 18, 2009
Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the operating room with medical
team training. Am J Surg. 2005;190(5):770-4.
https://psnet.ahrq.gov/issue/bridging-communication-gap-operating-r…
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psnet.ahrq.gov/node/36056/psn-pdf
September 27, 2010 - Path to safety: benefits of the 2005 Patient Safety and
Quality Improvement Act.
September 27, 2010
McBride D, Greening A, Redmond D. Path to safety: benefits of the 2005 Patient Safety and Quality
Improvement Act. Healthc Financ Manage. 2006;60(6):84-8.
https://psnet.ahrq.gov/issue/path-safety-benefits-2005-patie…
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psnet.ahrq.gov/node/36448/psn-pdf
November 22, 2006 - Do panels vary when assessing intrapartum adverse
events? The reproducibility of assessments by hospital
risk management groups.
November 22, 2006
Kernaghan D; Penney GC.
https://psnet.ahrq.gov/issue/do-panels-vary-when-assessing-intrapartum-adverse-events-reproducibility-
assessments-hospital
The authors analyz…
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psnet.ahrq.gov/node/867646/psn-pdf
January 01, 2022 - Opioid Safety Initiative Toolkit.
January 1, 2022
VA Pain Management, Opioid Safety, and PDMP (PMOP). U.S Department of Veterans Affairs; 2022.
Opioid Safety Initiative Toolkit.
https://psnet.ahrq.gov/issue/opioid-safety-initiative-toolkit
Increasing safe opioid prescribing is a patient safety priority. The VA’s O…
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psnet.ahrq.gov/node/40351/psn-pdf
April 06, 2011 - Acute care patients discuss the patient role in patient
safety.
April 6, 2011
Rathert C, Huddleston N, Pak Y. Acute care patients discuss the patient role in patient safety. Health Care
Manage Rev. 2011;36(2):134-144. doi:10.1097/HMR.0b013e318208cd31.
https://psnet.ahrq.gov/issue/acute-care-patients-discuss-patien…
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psnet.ahrq.gov/node/41850/psn-pdf
November 21, 2012 - TeamSTEPPS: the patient safety tool that needs to be
implemented.
November 21, 2012
Clapper TC, Kong M. TeamSTEPPS®: The Patient Safety Tool That Needs to Be Implemented. Clin Simul
Nurs. 2011;8(8). doi:10.1016/j.ecns.2011.03.002.
https://psnet.ahrq.gov/issue/teamstepps-patient-safety-tool-needs-be-implemented
De…
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psnet.ahrq.gov/node/45735/psn-pdf
July 17, 2017 - CMPA Good Practices Guide.
July 17, 2017
Ottawa, Ontario: Canadian Medical Protective Association; 2016.
https://psnet.ahrq.gov/issue/cmpa-good-practices-guide
Key patient safety topics include human factors, teamwork, adverse events, communication,
professionalism, and risk management. This website provides resou…
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psnet.ahrq.gov/node/36679/psn-pdf
December 21, 2009 - Manic for medication safety: bar codes and drug
information databases are helping to reduce medication
errors.
December 21, 2009
Rogoski RR. Manic for medication safety. Health management technology. 2007;28(2):14, 16-8.
https://psnet.ahrq.gov/issue/manic-medication-safety-bar-codes-and-drug-information-databases-…
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psnet.ahrq.gov/node/42601/psn-pdf
September 18, 2013 - 'You talking to me?' Docs and feedback.
September 18, 2013
Diamond F. 'You talking to me?' Docs and feedback. Managed care (Langhorne, Pa.). 2013;22(7):30-2.
https://psnet.ahrq.gov/issue/you-talking-me-docs-and-feedback
Reporting on barriers to teamwork, this magazine article relates how hierarchy influences speaki…
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psnet.ahrq.gov/node/42021/psn-pdf
February 13, 2013 - Nurses discuss bedside handover and using written
handover sheets.
February 13, 2013
Johnson M, Cowin LS. Nurses discuss bedside handover and using written handover sheets. J Nurs
Manag. 2013;21(1):121-9. doi:10.1111/j.1365-2834.2012.01438.x.
https://psnet.ahrq.gov/issue/nurses-discuss-bedside-handover-and-using-w…
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psnet.ahrq.gov/node/43510/psn-pdf
April 21, 2015 - Running a hospital patient safety campaign: a qualitative
study.
April 21, 2015
Ozieranski P, Robins V, Minion J, et al. Running a hospital patient safety campaign: a qualitative study. J
Health Organ Manag. 2014;28(4):562-75.
https://psnet.ahrq.gov/issue/running-hospital-patient-safety-campaign-qualitative-study
…
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psnet.ahrq.gov/node/34576/psn-pdf
May 27, 2015 - An Agenda for Research in Ambulatory Patient Safety.
May 27, 2015
Hammons T; Piland NF; Small SD; Hatlie MJ; Burstin HR; Medical Group Management Association; MGMA
https://psnet.ahrq.gov/issue/agenda-research-ambulatory-patient-safety
This summarizes a multidisciplinary conference (November 30 and December 1, 2000)…
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psnet.ahrq.gov/node/35933/psn-pdf
July 26, 2010 - Surgical 'never events': how common are adverse
occurrences?
July 26, 2010
West JC. Surgical ‘never events’: How common are adverse occurrences? Journal of Healthcare Risk
Management. 2009;26(1). doi:10.1002/jhrm.5600260105.
https://psnet.ahrq.gov/issue/surgical-never-events-how-common-are-adverse-occurrences
The…
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psnet.ahrq.gov/node/37125/psn-pdf
October 04, 2011 - Current pulse: can a production system reduce medical
errors in health care?
October 4, 2011
Printezis A, Gopalakrishnan M. Current pulse: can a production system reduce medical errors in health
care? Qual Manag Health Care. 2007;16(3):226-238.
https://psnet.ahrq.gov/issue/current-pulse-can-production-system-reduc…
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psnet.ahrq.gov/node/46998/psn-pdf
August 01, 2019 - 10 Facts on Patient Safety.
June 27, 2018
Patient Safety and Risk Management Service Delivery and Safety. Geneva, Switzerland; World Health
Organization: August 2019.
https://psnet.ahrq.gov/issue/10-facts-patient-safety
This publication highlights statistics that illustrate the global impact of patient harm. The i…
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psnet.ahrq.gov/node/39335/psn-pdf
September 24, 2016 - Interruptions and multitasking in nursing care.
September 24, 2016
Kalisch BJ, Aebersold M. Interruptions and multitasking in nursing care. Jt Comm J Qual Patient Saf.
2010;36(3):126-132.
https://psnet.ahrq.gov/issue/interruptions-and-multitasking-nursing-care
This study observed nurses for 4-hour periods and foun…
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psnet.ahrq.gov/node/35769/psn-pdf
January 02, 2017 - A web-based tool for the Comprehensive Unit-based
Safety Program (CUSP).
January 2, 2017
Pronovost P, King J, Holzmueller CG, et al. A web-based tool for the Comprehensive Unit-based Safety
Program (CUSP). Jt Comm J Qual Patient Saf. 2006;32(3):119-29.
https://psnet.ahrq.gov/issue/web-based-tool-comprehensive-unit…
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psnet.ahrq.gov/node/39113/psn-pdf
November 18, 2009 - From a blame culture to a just culture in health care.
November 18, 2009
Khatri N, Brown GD, Hicks LL. From a blame culture to a just culture in health care. Health Care Manag
Rev. 2009;34(4):312-322. doi:10.1097/HMR.0b013e3181a3b709.
https://psnet.ahrq.gov/issue/blame-culture-just-culture-health-care
This article…