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psnet.ahrq.gov/node/43005/psn-pdf
March 05, 2014 - "Chance favors only the prepared mind": preparing minds
to systematically reduce hazards in the testing process in
primary care.
March 5, 2014
Singh R, Hickner J, Mold J, et al. "Chance favors only the prepared mind": preparing minds to
systematically reduce hazards in the testing process in primary care. J Patien…
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psnet.ahrq.gov/node/836755/psn-pdf
March 16, 2022 - Adverse event and complication tracking in
anaesthesiology: dependence on self-reporting despite
implementation of electronic health records.
March 16, 2022
Tewfik G, Naftalovich R, Kaushal N, et al. Adverse event and complication tracking in anaesthesiology:
dependence on self-reporting despite implementation of …
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psnet.ahrq.gov/node/61048/psn-pdf
October 21, 2020 - Streamlining care in crisis: rapid creation and
implementation of a digital support tool for COVID-19.
October 21, 2020
Stark N, Kerrissey M, Grade M, et al. Streamlining care in crisis: rapid creation and implementation of a
digital support tool for COVID-19. West J Emerg Med. 2020;21(5):1095-1101.
doi:10.5811/we…
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psnet.ahrq.gov/node/844759/psn-pdf
September 18, 2019 - Saving Patient Ryan- can advanced electronic medical
records make patient care safer?
September 18, 2019
Hydari MZ, Telang R, Marella WM. Manage Sci. 2019;65:2041-2059.
https://psnet.ahrq.gov/issue/saving-patient-ryan-can-advanced-electronic-medical-records-make-patient-
care-safer
This observational study examin…
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psnet.ahrq.gov/node/46821/psn-pdf
June 06, 2018 - Focus on the Quadruple Aim: development of a resiliency
center to promote faculty and staff wellness initiatives.
June 6, 2018
Morrow E, Call M, Marcus R, et al. Focus on the Quadruple Aim: Development of a Resiliency Center to
Promote Faculty and Staff Wellness Initiatives. Jt Comm J Qual Patient Saf. 2018;44(5):2…
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psnet.ahrq.gov/node/837860/psn-pdf
August 17, 2022 - Alcoholism and American healthcare: the case for a
patient safety approach.
August 17, 2022
Zipperer L, Ryan R, Jones B. Alcoholism and American healthcare: the case for a patient safety approach.
J Patient Saf Risk Manag. 2022;27(5):201-208. doi:10.1177/25160435221117952.
https://psnet.ahrq.gov/issue/alcoholism-a…
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psnet.ahrq.gov/node/44653/psn-pdf
November 18, 2015 - Data quality associated with handwritten laboratory test
requests: classification and frequency of data-entry
errors for outpatient serology tests.
November 18, 2015
Vecellio E, Toouli G, Georgiou A, et al. Data quality associated with handwritten laboratory test requests:
classification and frequency of data-entr…
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psnet.ahrq.gov/node/866958/psn-pdf
October 16, 2024 - Beyond error: a qualitative study of human factors in
serious adverse events.
October 16, 2024
Mujuru C, Peisah C. Beyond error: a qualitative study of human factors in serious adverse events. J
Healthc Risk Manag. 2024;44(2):7-13. doi:10.1002/jhrm.21583.
https://psnet.ahrq.gov/issue/beyond-error-qualitative-study…
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psnet.ahrq.gov/node/60046/psn-pdf
March 18, 2020 - Adverse outcomes of polypharmacy in older people:
systematic review of reviews.
March 18, 2020
Davies LE, Spiers G, Kingston A, et al. Adverse outcomes of polypharmacy in older people: systematic
review of reviews. J Am Med Dir Assoc. 2020;21(2):181-187. doi:10.1016/j.jamda.2019.10.022.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/849136/psn-pdf
May 17, 2023 - Using morbidity and mortality conferences to drive
quality improvement and reduce errors.
May 17, 2023
Lai B, Horn J, Wilkinson J, et al. Fam Pract Manag. 2023;30(2):13-17.
https://psnet.ahrq.gov/issue/using-morbidity-and-mortality-conferences-drive-quality-improvement-and-
reduce-errors
Morbidity and mortality (…
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psnet.ahrq.gov/node/866346/psn-pdf
July 24, 2024 - A human right-based approach to dealing with adverse
events in residential care facilities.
July 24, 2024
McGrane N, Behan L, Keyes LM. A human right-based approach to dealing with adverse events in
residential care facilities. Health Hum Rights. 2024;26(1):115-128.
https://psnet.ahrq.gov/issue/human-right-based-a…
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psnet.ahrq.gov/node/60292/psn-pdf
May 06, 2020 - Overcoming COVID-19: what can human factors and
ergonomics offer?
May 6, 2020
Gurses AP, Tschudy MM, McGrath-Morrow S, et al. Overcoming COVID-19: what can human factors and
ergonomics offer? J Patient Saf Risk Manag. 2020;25(2):49-54. doi:10.1177/2516043520917764.
https://psnet.ahrq.gov/issue/overcoming-covid-19-…
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psnet.ahrq.gov/node/73388/psn-pdf
June 16, 2021 - Reducing surgical specimen errors through
multidisciplinary quality improvement.
June 16, 2021
Holstine JB, Samora JB. Reducing surgical specimen errors through multidisciplinary quality improvement.
Jt Comm J Qual Patient Saf. 2021;47(9):563-571. doi:10.1016/j.jcjq.2021.04.003.
https://psnet.ahrq.gov/issue/reduci…
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psnet.ahrq.gov/node/74169/psn-pdf
December 08, 2021 - Pointing fingers: verbosity of patient safety narratives is
associated with attribution of blame.
December 8, 2021
Ackerman RS, Patel SY, Costache M, et al. Anesthesiology News. November 21, 2021.
https://psnet.ahrq.gov/issue/pointing-fingers-verbosity-patient-safety-narratives-associated-attribution-
bl…
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psnet.ahrq.gov/node/43127/psn-pdf
April 23, 2014 - An interprofessional qualitative study of barriers and
potential solutions for the safe use of insulin in the
hospital setting.
April 23, 2014
Rousseau M-P, Beauchesne M-F, Naud A-S, et al. An interprofessional qualitative study of barriers and
potential solutions for the safe use of insulin in the hospital settin…
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psnet.ahrq.gov/node/47837/psn-pdf
May 11, 2019 - Association of hospital employee satisfaction with patient
safety and satisfaction within Veterans Affairs medical
centers.
May 11, 2019
Kang R, Kunkel ST, Columbo JA, et al. Association of Hospital Employee Satisfaction with Patient Safety
and Satisfaction within Veterans Affairs Medical Centers. Am J Med. 2019;1…
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psnet.ahrq.gov/node/46319/psn-pdf
August 09, 2017 - Opioids in Medicare Part D: Concerns About Extreme Use
and Questionable Prescribing.
August 9, 2017
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; July
2017. Report No. OEI-02-17-00250.
https://psnet.ahrq.gov/issue/opioids-medicare-part-d-concerns-about-extreme-use-and…
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psnet.ahrq.gov/node/44422/psn-pdf
November 17, 2017 - Stop the noise: a quality improvement project to decrease
electrocardiographic nuisance alarms.
November 17, 2017
Sendelbach S, Wahl S, Anthony A, et al. Stop the Noise: A Quality Improvement Project to Decrease
Electrocardiographic Nuisance Alarms. Crit Care Nurse. 2015;35(4):15-22; quiz 1p following 22.
doi:10.4…
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psnet.ahrq.gov/node/837806/psn-pdf
August 10, 2022 - Do patient engagement IT functionalities influence patient
safety outcomes? A study of US hospitals.
August 10, 2022
Upadhyay S, Opoku-Agyeman W, Choi S, et al. Do patient engagement IT functionalities influence patient
safety outcomes? A study of US hospitals. J Public Health Manag Pract. 2022;28(5):505-512.
doi:…
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psnet.ahrq.gov/node/72832/psn-pdf
March 10, 2021 - Communication and Transparency as a Means to
Strengthening Workplace Culture During COVID-19.
March 10, 2021
Nadkarni A, Levy-Carrick NC, Kroll DS, et al. Communication And Transparency As A Means To
Strengthening Workplace Culture During Covid-19. National Academy of Medicine; 2021.
doi:10.31478/202103a.
https:/…