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psnet.ahrq.gov/node/43941/psn-pdf
February 25, 2015 - How to make surgery safer.
February 25, 2015
https://psnet.ahrq.gov/issue/how-make-surgery-safer
This newspaper article reports on various ways hospitals are working to make surgical care safer and
reduce readmissions due to surgical complications, including checklists, teamwork training courses for
surgeons, preo…
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psnet.ahrq.gov/node/40689/psn-pdf
August 17, 2011 - Non-clinical errors using voice recognition dictation
software for radiology reports: a retrospective audit.
August 17, 2011
Chang CA, Strahan R, Jolley D. Non-clinical errors using voice recognition dictation software for radiology
reports: a retrospective audit. J Digit Imaging. 2011;24(4):724-8. doi:10.1007/s102…
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psnet.ahrq.gov/node/40285/psn-pdf
March 09, 2011 - ASHP statement on bar-code verification during
inventory, preparation, and dispensing of medications.
March 9, 2011
ASHP statement on bar-code verification during inventory, preparation, and dispensing of medications. Am
J Health-Syst Pharm. 2011;68:442-445. doi:10.2146/sp100012.
https://psnet.ahrq.gov/issue/ashp-…
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psnet.ahrq.gov/node/45237/psn-pdf
June 15, 2016 - Medication reconciliation in oncological patients: a
randomized clinical trial.
June 15, 2016
Vega TG-C, Sierra-Sánchez JF, Martínez-Bautista MJ, et al. Medication Reconciliation in Oncological
Patients: A Randomized Clinical Trial. J Manag Care Spec Pharm. 2016;22(6):734-40.
doi:10.18553/jmcp.2016.15248.
https:/…
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psnet.ahrq.gov/node/73123/psn-pdf
April 01, 2020 - Digital Healthcare Research.
April 1, 2020
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/digital-healthcare-research
An understanding of the impact that digital tools can have on clinical decision making, patient self-care, and
health system improvement is still emerging. This website hi…
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psnet.ahrq.gov/node/41416/psn-pdf
May 23, 2012 - Checking anaesthetic equipment 2012: Association of
Anaesthetists of Great Britain and Ireland.
May 23, 2012
Anderson E, Bythell V, Gemmell L, et al. Checking Anaesthetic Equipment 2012. Anaesthesia. 2012;67(6).
doi:10.1111/j.1365-2044.2012.07163.x.
https://psnet.ahrq.gov/issue/checking-anaesthetic-equipment-2012-…
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psnet.ahrq.gov/node/72562/psn-pdf
December 09, 2020 - Missed or Rationed Nursing Care.
December 9, 2020
J Nurs Manag. 2020;28(8): i-iv, 1767-2275.
https://psnet.ahrq.gov/issue/missed-or-rationed-nursing-care
Incomplete nursing care is known to affect care quality and safety. This special issue documents the global
problem of missed or rationed nursing care in a varie…
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psnet.ahrq.gov/node/47588/psn-pdf
November 21, 2018 - 2 MSO programs show value of safety position.
November 21, 2018
Wild D. Pharmacy Practice News. November 8, 2018.
https://psnet.ahrq.gov/issue/2-mso-programs-show-value-safety-position
Medication safety officers serve as organizational champions of medication management process
improvement. This news article offer…
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psnet.ahrq.gov/node/45311/psn-pdf
May 20, 2019 - The Joint Commission Big Book of Checklists. 2nd
Edition.
May 20, 2019
Oakbrook Terrance, IL: Joint Commission; 2018. ISBN: 9781635850598.
https://psnet.ahrq.gov/issue/joint-commission-big-book-checklists-2nd-edition
Checklists are a widely accepted strategy to improve communication and standardize processes to su…
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psnet.ahrq.gov/node/40728/psn-pdf
October 21, 2011 - What prevents incident disclosure, and what can be done
to promote it?
October 21, 2011
Iedema R, Allen S, Sorensen R, et al. What prevents incident disclosure, and what can be done to promote
it? Jt Comm J Qual Patient Saf. 2011;37(9):409-417.
https://psnet.ahrq.gov/issue/what-prevents-incident-disclosure-and-wha…
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psnet.ahrq.gov/node/43241/psn-pdf
June 11, 2014 - "It is the left eye, right?"
June 11, 2014
Pikkel D, Sharabi-Nov A, Pikkel J. "It is the left eye, right?". Risk Manag Healthc Policy. 2014;7:77-80.
doi:10.2147/RMHP.S60728.
https://psnet.ahrq.gov/issue/it-left-eye-right
In this study, cataract surgeons were asked to identify the correct eye for surgery when given…
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psnet.ahrq.gov/node/45338/psn-pdf
July 20, 2016 - Understanding models of error and how they apply in
clinical practice.
July 20, 2016
Garfield S, Franklin BD. Pharm J. June 14, 2016.
https://psnet.ahrq.gov/issue/understanding-models-error-and-how-they-apply-clinical-practice
Human error and fallibility are a part of health care delivery that can be exacerbated b…
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psnet.ahrq.gov/node/46607/psn-pdf
November 08, 2017 - Stem the Tide: Addressing the Opioid Epidemic.
November 8, 2017
Chicago, IL: American Hospital Association; 2017.
https://psnet.ahrq.gov/issue/stem-tide-addressing-opioid-epidemic
The opioid epidemic is a challenge to patient safety and public health. This report reviews tools to help
health care systems target ei…
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psnet.ahrq.gov/node/36221/psn-pdf
October 20, 2010 - Enhancing patient safety during hand-offs: standardized
communication and teamwork using the 'SBAR' method.
October 20, 2010
Hohenhaus S, Powell S, Hohenhaus JT. Am J Nurs. 2006;106(8):72A-72B.
https://psnet.ahrq.gov/issue/enhancing-patient-safety-during-hand-offs-standardized-communication-and-
teamwork-using-sba…
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psnet.ahrq.gov/node/50864/psn-pdf
February 05, 2020 - I'm sorry: laws that support apologies in health care.
February 5, 2020
Atkinson Smith M. I?m Sorry. Prof Case Manag. 2019;25(1):40-45. doi:10.1097/ncm.0000000000000410.
https://psnet.ahrq.gov/issue/im-sorry-laws-support-apologies-health-care
Apology laws have been passed by numerous states and the District of Colu…
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psnet.ahrq.gov/web-mm/see-patient-first
September 27, 2023 - But See the Patient First
Citation Text:
Sinigayan VR. But See the Patient First. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
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psnet.ahrq.gov/node/49737/psn-pdf
June 01, 2015 - Unseen Perils of Urinary Catheters
June 1, 2015
Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
The Case
A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…
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psnet.ahrq.gov/node/33826/psn-pdf
February 01, 2017 - In Conversation With… Amy C. Edmondson, PhD, AM
February 1, 2017
In Conversation With… Amy C. Edmondson, PhD, AM. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
Editor's note: Dr. Edmondson is professor of Leadership and Management at Harvard Business School.
Her la…
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psnet.ahrq.gov/classics
August 01, 2023 - Classics and Emerging Classics
To help our readers navigate the tremendous breadth of the PSNet Collection, AHRQ PSNet editors and advisors have given the designation of “Classic” to review articles, empirical studies, government and stakeholder reports, commentaries, and books of lasting importance to the patient sa…
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psnet.ahrq.gov/node/838900/psn-pdf
October 27, 2022 - Fecal Contamination of the Peritoneum from
Laparoscopic Trocar Injury: A Routine Operation Goes
Wrong.
October 27, 2022
Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine
Operation Goes Wrong. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/fecal-contamination-…