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psnet.ahrq.gov/node/45149/psn-pdf
September 19, 2016 - Care at the point of impact: insights into the second-
victim experience.
September 19, 2016
Scott SD, McCoig MM. Care at the point of impact: Insights into the second-victim experience. J Healthc
Risk Manag. 2016;35(4):6-13. doi:10.1002/jhrm.21218.
https://psnet.ahrq.gov/issue/care-point-impact-insights-second-vi…
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psnet.ahrq.gov/node/60280/psn-pdf
April 29, 2020 - Missed, rationed or unfinished nursing care: a scoping
review of patient outcomes.
April 29, 2020
Kalánková D, Kirwan M, Bartoní?ková D, et al. Missed, rationed or unfinished nursing care: A scoping
review of patient outcomes. J Nurs Manag. 2020;28(8):1783-1797. doi:10.1111/jonm.12978.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/72634/psn-pdf
January 13, 2021 - How U.S. teams advanced communication and resolution
program adoption at local, state and national levels.
January 13, 2021
LeCraw FR, Stearns SC, McCoy MJ. How U.S. Teams advanced communication and resolution program
adoption at local, state and national levels. J Patient Saf Risk Manag. 2021;26(1):34-40.
doi:10.…
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psnet.ahrq.gov/node/45766/psn-pdf
February 08, 2017 - Prescription Drug Monitoring Programs: Evidence-based
Practices to Optimize Prescriber Use.
February 8, 2017
Philadelphia, PA: Pew Charitable Trusts and Institute for Behavioral Health, Heller School for Social Policy
and Management at Brandeis University; 2016.
https://psnet.ahrq.gov/issue/prescription-drug-monit…
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psnet.ahrq.gov/node/45971/psn-pdf
April 21, 2018 - Guide to Improving Patient Safety in Primary Care
Settings by Engaging Patients and Families.
April 21, 2018
Rockville, MD: Agency for Healthcare Research and Quality; April 2018.
https://psnet.ahrq.gov/issue/guide-improving-patient-safety-primary-care-settings-engaging-patients-and-
families
Patient engagement i…
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psnet.ahrq.gov/node/837419/psn-pdf
June 15, 2022 - Implicit racial bias in pediatric orthopaedic surgery.
June 15, 2022
Guzek R, Goodbody CM, Jia L, et al. Implicit racial bias in pediatric orthopaedic surgery. J Pediatr Orthop.
2022;42(7):393-399. doi:10.1097/bpo.0000000000002170.
https://psnet.ahrq.gov/issue/implicit-racial-bias-pediatric-orthopaedic-surgery
Res…
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psnet.ahrq.gov/node/46054/psn-pdf
January 01, 2021 - Misuse of pediatric medications and parent–physician
communication: an interactive voice response
intervention.
April 12, 2017
Walsh KE, Bacic J, Phillips BD, et al. Misuse of Pediatric Medications and Parent-Physician
Communication: An Interactive Voice Response Intervention. J Patient Saf. 2021;17(3):e177-e185.
…
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psnet.ahrq.gov/node/837894/psn-pdf
August 24, 2022 - Identifying boundary spanning reporter roles in patient
safety events.
August 24, 2022
Hurley VB, Boxley C, Sloss EA, et al. Identifying boundary spanning reporter roles in patient safety events.
J Patient Saf Risk Manag. 2022;27(4):181-187. doi:10.1177/25160435221103096.
https://psnet.ahrq.gov/issue/identifying-b…
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psnet.ahrq.gov/node/40096/psn-pdf
December 22, 2010 - Enhancing communication in surgery through team
training interventions: a systematic literature review.
December 22, 2010
Gillespie BM, Chaboyer W, Murray P. Enhancing communication in surgery through team training
interventions: a systematic literature review. AORN J. 2010;92(6):642-57. doi:10.1016/j.aorn.2010.02.…
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psnet.ahrq.gov/node/44101/psn-pdf
November 06, 2015 - Association between exposure to nonactionable
physiologic monitor alarms and response time in a
children's hospital.
November 6, 2015
Bonafide CP, Lin R, Zander M, et al. Association between exposure to nonactionable physiologic monitor
alarms and response time in a children's hospital. J Hosp Med. 2015;10(6):345-…
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psnet.ahrq.gov/node/848082/psn-pdf
April 26, 2023 - Adopting high reliability organization principles to lead a
large scale clinical transformation.
April 26, 2023
Pozzobon LD, Lam J, Chimonides E, et al. Adopting high reliability organization principles to lead a large
scale clinical transformation. Healthc Manage Forum. 2023;36(4):241-245.
doi:10.1177/08404704231…
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psnet.ahrq.gov/node/48174/psn-pdf
January 01, 2020 - The ageing surgeon: a qualitative study of expert
opinions on assuring performance and supporting safe
career transitions among older surgeons.
August 21, 2019
Sherwood R, Bismark M. The ageing surgeon: a qualitative study of expert opinions on assuring
performance and supporting safe career transitions among olde…
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psnet.ahrq.gov/node/34670/psn-pdf
January 01, 2006 - Hindsight ? foresight: the effect of outcome knowledge
on judgment under uncertainty.
March 7, 2005
Fischhoff B. Hindsight is not equal to foresight: The effect of outcome knowledge on judgment under
uncertainty. Journal of Experimental Psychology: Human Perception and Performance. 2006;1(3).
doi:10.1037/0096-1523…
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psnet.ahrq.gov/node/837070/psn-pdf
May 11, 2022 - Patient falls in the operating room setting: an analysis of
reported safety events.
May 11, 2022
Tan J, Krishnan S, Vacanti JC, et al. Patient falls in the operating room setting: an analysis of reported
safety events. J Healthc Risk Manag. 2022;42(1):9-14. doi:10.1002/jhrm.21503.
https://psnet.ahrq.gov/issue/pati…
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psnet.ahrq.gov/node/50378/psn-pdf
September 25, 2019 - Evaluating horizontal violence and bullying in the nursing
workforce of an oncology academic medical center.
September 25, 2019
Lewis-Pierre LT, Anglade D, Saber D, et al. Evaluating horizontal violence and bullying in the nursing
workforce of an oncology academic medical center. J Nurs Manag. 2019;27(5):1005-1010.…
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psnet.ahrq.gov/node/47478/psn-pdf
January 16, 2019 - Prospective daily review of discharge medications by
pharmacists: effects on measures of safety and
efficiency.
January 16, 2019
Craynon R, Hager DR, Reed M, et al. Prospective daily review of discharge medications by pharmacists:
Effects on measures of safety and efficiency. Am J Health Syst Pharm. 2018;75(19):14…
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psnet.ahrq.gov/node/854255/psn-pdf
October 04, 2023 - Empowering telemetry technicians and enhancing
communication to improve in-hospital cardiac arrest
survival.
October 4, 2023
McCoy C, Keshvani N, Warsi M, et al. Empowering telemetry technicians and enhancing communication to
improve in-hospital cardiac arrest survival. BMJ Open Qual. 2023;12(3):e002220. doi:10.11…
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psnet.ahrq.gov/node/44877/psn-pdf
April 27, 2016 - Actions Needed to Help Ensure Appropriate Medication
Continuation and Prescribing Practices.
April 27, 2016
Washington, DC: United States Government Accountability Office; January 5, 2016. Publication GAO-16-
158.
https://psnet.ahrq.gov/issue/actions-needed-help-ensure-appropriate-medication-continuation-and-
pre…
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psnet.ahrq.gov/node/43175/psn-pdf
December 12, 2014 - Interventions to improve safe and effective medicines use
by consumers: an overview of systematic reviews.
December 12, 2014
Ryan R, Santesso N, Lowe D, et al. Interventions to improve safe and effective medicines use by
consumers: an overview of systematic reviews. Cochrane Database Syst Rev. 2014;(4):CD007768.
d…
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psnet.ahrq.gov/node/44391/psn-pdf
January 22, 2016 - Safety culture in cardiac surgical teams: data from five
programs and national surgical comparison.
January 22, 2016
Marsteller JA, Wen M, Hsu Y-J, et al. Safety Culture in Cardiac Surgical Teams: Data From Five Programs
and National Surgical Comparison. Ann Thorac Surg. 2015;100(6):2182-9.
doi:10.1016/j.athoracsu…