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psnet.ahrq.gov/node/44307/psn-pdf
November 06, 2015 - The non-technical skills used by anaesthetic technicians
in critical incidents reported to the Australian Incident
Monitoring System between 2002 and 2008.
November 6, 2015
Rutherford JS, Flin R, Irwin A. The non-technical skills used by anaesthetic technicians in critical incidents
reported to the Australian Inci…
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psnet.ahrq.gov/node/43298/psn-pdf
June 25, 2014 - Electronic prescribing: improving the efficiency and
accuracy of prescribing in the ambulatory care setting.
June 25, 2014
Porterfield A, Engelbert K, Coustasse A. Electronic prescribing: improving the efficiency and accuracy of
prescribing in the ambulatory care setting. Perspect Health Inf Manag. 2014;11:1g.
htt…
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psnet.ahrq.gov/node/43445/psn-pdf
October 01, 2014 - Test result communication in primary care: clinical and
office staff perspectives.
October 1, 2014
Litchfield I, Bentham L, Lilford RJ, et al. Test result communication in primary care: clinical and office staff
perspectives. Fam Pract. 2014;31(5):592-7. doi:10.1093/fampra/cmu041.
https://psnet.ahrq.gov/issue/test…
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psnet.ahrq.gov/node/47958/psn-pdf
June 26, 2019 - Patient safety professionals as the third victims of
adverse events.
June 26, 2019
Holden J, Card AJ. Patient safety professionals as the third victims of adverse events. J Patient Saf Risk
Manag. 2019;24(4):166-175. doi:10.1177/2516043519850914.
https://psnet.ahrq.gov/issue/patient-safety-professionals-third-vict…
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psnet.ahrq.gov/node/47319/psn-pdf
October 10, 2018 - Differences in strength expression on product labels of
compounders and conventional manufacturers may lead
to dosing errors.
October 10, 2018
US Food and Drug Administration; FDA.
https://psnet.ahrq.gov/issue/differences-strength-expression-product-labels-compounders-and-
conventional-manufacturers-may
Confusin…
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psnet.ahrq.gov/node/42709/psn-pdf
November 06, 2013 - Toward increased patient safety? Electronic
communication of medication information between
nurses in home health care and general practitioners.
November 6, 2013
Lyngstad M, Melby L, Grimsmo A, et al. Toward Increased Patient Safety? Electronic Communication of
Medication Information Between Nurses in Home Health…
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psnet.ahrq.gov/node/850341/psn-pdf
June 14, 2023 - Impact of fatigue on anaesthesia providers: a scoping
review.
June 14, 2023
Scholliers A, Cornelis S, Tosi M, et al. Impact of fatigue on anaesthesia providers: a scoping review. Br J
Anaesth. 2023;130(5):622-635. doi:10.1016/j.bja.2022.12.011.
https://psnet.ahrq.gov/issue/impact-fatigue-anaesthesia-providers-scop…
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psnet.ahrq.gov/node/50925/psn-pdf
February 19, 2020 - Report of the Independent Inquiry into the Issues Raised
by Paterson.
February 19, 2020
James G. House Commons Report 31. Department of Health and Social Care. London,
England: Crown Copyright; 2020. ISBN 9781528617284.
https://psnet.ahrq.gov/issue/report-independent-inquiry-issues-raised-paterson
Shari…
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psnet.ahrq.gov/node/73685/psn-pdf
September 08, 2021 - Obstetric iatrogenesis in the United States: the spectrum
of unintentional harm, disrespect, violence, and abuse.
September 8, 2021
Liese KL, Davis-Floyd R, Stewart K, et al. Obstetric iatrogenesis in the United States: the spectrum of
unintentional harm, disrespect, violence, and abuse. Anthropol Med. 2021;28(2):1…
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psnet.ahrq.gov/node/47555/psn-pdf
November 14, 2018 - How one hospital improved patient safety in 10 minutes a
day.
November 14, 2018
van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018.
https://psnet.ahrq.gov/issue/how-one-hospital-improved-patient-safety-10-minutes-day
Aviation continues to provide inspiration for patient safety innovation. This commentar…
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psnet.ahrq.gov/node/39740/psn-pdf
August 11, 2010 - Development and pilot testing of guidelines to monitor
high-risk medications in the ambulatory setting.
August 11, 2010
Tjia J, Field T, Garber LD, et al. Development and pilot testing of guidelines to monitor high-risk
medications in the ambulatory setting. Am J Manag Care. 2010;16(7):489-96.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/39834/psn-pdf
July 02, 2014 - Improving resident education and patient safety: a
method to balance initial caseloads at academic year-end
transfer.
July 2, 2014
Young JQ, Niehaus B, Lieu SC, et al. Improving resident education and patient safety: a method to balance
initial caseloads at academic year-end transfer. Acad Med. 2010;85(9):1418-24.…
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psnet.ahrq.gov/node/47159/psn-pdf
August 01, 2018 - Safety II behavior in a pediatric intensive care unit.
August 1, 2018
Merandi J, Vannatta K, Davis T, et al. Safety II Behavior in a Pediatric Intensive Care Unit. Pediatrics.
2018;141(6):e20180018. doi:10.1542/peds.2018-0018.
https://psnet.ahrq.gov/issue/safety-ii-behavior-pediatric-intensive-care-unit
The tradit…
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psnet.ahrq.gov/node/44032/psn-pdf
April 01, 2015 - ACOG Committee Opinion #621: patient safety and health
information technology.
April 1, 2015
Improvement C on PS and Q, Management C on P. Committee opinion no. 621: Patient safety and health
information technology. Obstet Gynecol. 2015;125(1):282-3. doi:10.1097/01.AOG.0000459867.14114.7a.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/60626/psn-pdf
June 24, 2020 - A nursing home’s 64-day Covid siege: ‘They’re all going
to die’.
June 24, 2020
Barker K. A nursing home’s 64-day Covid siege: ‘They’re all going to die’. New York Times. 2020;June 10.
https://psnet.ahrq.gov/issue/nursing-homes-64-day-covid-siege-theyre-all-going-die
This feature story describes the COVID-19 experi…
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psnet.ahrq.gov/node/40697/psn-pdf
October 31, 2011 - Real-time automated paging and decision support for
critical laboratory abnormalities.
October 31, 2011
Etchells E, Adhikari NKJ, Wu RC, et al. Real-time automated paging and decision support for critical
laboratory abnormalities. BMJ Qual Saf. 2011;20(11):924-30. doi:10.1136/bmjqs.2010.051110.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/73185/psn-pdf
April 28, 2021 - Balancing patient safety, clinical efficacy, and
cybersecurity with clinician partners.
April 28, 2021
Schneider J, Wirth A. Balancing patient safety, clinical efficacy, and cybersecurity with clinician partners.
Biomed Instrum Technol. 2021;55(1):21-28. doi:10.2345/0899-8205-55.1.21.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/43034/psn-pdf
March 12, 2014 - Implementation of a pediatric rapid response team:
experience of the Hospital for Sick Children in Toronto.
March 12, 2014
Kukreti V, Gaiteiro R, Mohseni-Bod H. Implementation of a pediatric rapid response team: experience of
the Hospital for Sick Children in Toronto. Indian Pediatr. 2014;51(1):11-5.
https://psnet…
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psnet.ahrq.gov/node/45042/psn-pdf
September 07, 2016 - The aging surgeon.
September 7, 2016
Katlic MR, Coleman JA. The Aging Surgeon. Adv Surg. 2016;50(1):93-103.
doi:10.1016/j.yasu.2016.03.008.
https://psnet.ahrq.gov/issue/aging-surgeon
Senior clinicians often elicit respect from their junior colleagues. This respect can affect colleagues'
willingness to intervene s…
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psnet.ahrq.gov/node/47970/psn-pdf
May 01, 2019 - Can we import improvements from industry to
healthcare?
May 1, 2019
Macrae C, Stewart K. Can we import improvements from industry to healthcare? BMJ. 2019;364:l1039.
doi:10.1136/bmj.l1039.
https://psnet.ahrq.gov/issue/can-we-import-improvements-industry-healthcare
Principles from high-risk industries can be appli…