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psnet.ahrq.gov/node/60234/psn-pdf
April 15, 2020 - Mistakes, Errors and Failures across Cultures.
April 15, 2020
Vanderheiden E, Mayer C, eds. Springer Nature. Cham, Switzerland: 2020. ISBN 9783030355739
https://psnet.ahrq.gov/issue/mistakes-errors-and-failures-across-cultures-navigating-potentials
Human error, mistakes and failure have cultural aspects that are im…
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psnet.ahrq.gov/node/37722/psn-pdf
February 18, 2011 - Leveraging computerized sign-out to increase error
reporting and addressing patient safety in graduate
medical education.
February 18, 2011
Foster PN, Sidhu R, Gadhia DA, et al. Leveraging computerized sign-out to increase error reporting and
addressing patient safety in graduate medical education. J Gen Intern Me…
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psnet.ahrq.gov/node/44893/psn-pdf
March 09, 2016 - Improving the governance of patient safety in emergency
care: a systematic review of interventions.
March 9, 2016
Hesselink G, Berben S, Beune T, et al. Improving the governance of patient safety in emergency care: a
systematic review of interventions. BMJ Open. 2016;6(1):e009837. doi:10.1136/bmjopen-2015-009837.
…
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psnet.ahrq.gov/node/46440/psn-pdf
September 20, 2017 - Why do people stop taking their meds? Cost is just one
reason.
September 20, 2017
Hobson K. Health Shots. National Public Radio. September 8, 2017.
https://psnet.ahrq.gov/issue/why-do-people-stop-taking-their-meds-cost-just-one-reason
Medication regimen nonadherence can result in patient harm. This news article re…
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psnet.ahrq.gov/node/44785/psn-pdf
January 27, 2016 - Reducing Adverse Drug Events Related to Opioids
Implementation Guide.
January 27, 2016
Frederickson TW. Gordon DB, De Pinto M, et al. Philadelphia, PA: Society of Hospital Medicine; 2015.
https://psnet.ahrq.gov/issue/reducing-adverse-drug-events-related-opioids-implementation-guide
Opioids are high-risk medication…
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psnet.ahrq.gov/node/845276/psn-pdf
March 01, 2023 - Cognitive biases in surgery: systematic review.
March 1, 2023
Armstrong BA, Dutescu IA, Tung A, et al. Cognitive biases in surgery: systematic review. Br J Surg.
2023;110(6):645-654. doi:10.1093/bjs/znad004.
https://psnet.ahrq.gov/issue/cognitive-biases-surgery-systematic-review
Cognitive biases are a known source…
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psnet.ahrq.gov/node/41434/psn-pdf
June 06, 2012 - ASHP national survey of pharmacy practice in hospital
settings: prescribing and transcribing—2010.
June 6, 2012
Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital
settings: prescribing and transcribing--2010. Am J Health Syst Pharm. 2011;68(8):669-88.
doi:10.2146/ajhp…
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psnet.ahrq.gov/node/46263/psn-pdf
July 12, 2017 - The texting debate: beneficial means of communication or
safety and security risk?
July 12, 2017
ISMP Medication Safety Alert! Acute Care Edition. June 29, 2017;16:1-5.
https://psnet.ahrq.gov/issue/texting-debate-beneficial-means-communication-or-safety-and-security-risk
Adopting new technologies in health care ca…
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psnet.ahrq.gov/node/45369/psn-pdf
October 29, 2017 - The aging physician and the medical profession: a review.
October 29, 2017
Dellinger P, Pellegrini CA, Gallagher TH. The Aging Physician and the Medical Profession: A Review.
JAMA Surg. 2017;152(10):967-971. doi:10.1001/jamasurg.2017.2342.
https://psnet.ahrq.gov/issue/aging-physician-and-medical-profession-review
…
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psnet.ahrq.gov/node/44123/psn-pdf
July 11, 2018 - The 2014 John M. Eisenberg Patient Safety and Quality
Awards.
July 11, 2018
Jt Comm J Qual Patient Saf. 2015;41(5):195-211.
https://psnet.ahrq.gov/issue/2014-john-m-eisenberg-patient-safety-and-quality-awards
Articles in this special issue highlight the achievements of the 2014 John M. Eisenberg Patient Safety and…
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psnet.ahrq.gov/node/45982/psn-pdf
August 03, 2017 - Workplace factors associated with burnout of family
physicians.
August 3, 2017
Rassolian M, Peterson LE, Fang B, et al. Workplace Factors Associated With Burnout of Family
Physicians. JAMA Intern Med. 2017;177(7):1036-1038. doi:10.1001/jamainternmed.2017.1391.
https://psnet.ahrq.gov/issue/workplace-factors-associa…
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psnet.ahrq.gov/node/61123/psn-pdf
November 11, 2020 - Organizational Evidence-Based and Promising Practices
for Improving Clinician Well-Being.
November 11, 2020
Sinsky CA, Biddison LD, Mallick A, et al. NAM Perspectives. Washington DC: National Academy of
Medicine; 2020.
https://psnet.ahrq.gov/issue/organizational-evidence-based-and-promising-practices-improvin…
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psnet.ahrq.gov/node/38735/psn-pdf
June 24, 2009 - Reflection and analysis of how pharmacy students learn
to communicate about medication errors.
June 24, 2009
Noland CM, Rickles NM. Reflection and analysis of how pharmacy students learn to communicate about
medication errors. Health Commun. 2009;24(4):351-60. doi:10.1080/10410230902889399.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/60265/psn-pdf
January 01, 2019 - Quality Improvement and Patient Safety Competencies
Across the Learning Continuum.
January 1, 2019
AAMC New and Emerging Areas in Medicine Series. Washington, DC: Association of American Medical
Colleges; 2019. ISBN: 9781577541882.
https://psnet.ahrq.gov/issue/quality-improvement-and-patient-safety-competencies-ac…
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psnet.ahrq.gov/node/38830/psn-pdf
February 18, 2011 - Are opioid dependence and methadone maintenance
treatment (MMT) documented in the medical record? A
patient safety issue.
February 18, 2011
Walley AY, Farrar D, Cheng DM, et al. Are opioid dependence and methadone maintenance treatment
(MMT) documented in the medical record? A patient safety issue. J Gen Intern Me…
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psnet.ahrq.gov/node/44667/psn-pdf
March 15, 2016 - Incorporating metacognition into morbidity and mortality
rounds: the next frontier in quality improvement.
March 15, 2016
Katz D, Detsky AS. Incorporating metacognition into morbidity and mortality rounds: The next frontier in
quality improvement. J Hosp Med. 2016;11(2):120-2. doi:10.1002/jhm.2505.
https://psnet.a…
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psnet.ahrq.gov/node/73407/psn-pdf
June 16, 2021 - Common Formats for Patient Safety Data Collection:
Diagnostic Safety 0.1.
June 16, 2021
The Agency for Healthcare Research and Quality. Fed Register. 2021;86(103): 29263-29264.
https://psnet.ahrq.gov/issue/common-formats-patient-safety-data-collection-diagnostic-safety-01
Measurement of diagnostic errors is an imp…
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psnet.ahrq.gov/node/73100/psn-pdf
March 31, 2021 - Public comment period extended for strategies to
improve patient safety: Draft Report to Congress for
Public Comment and Review by the National Academy of
Medicine.
March 31, 2021
Fed Register. 2021;86(51):14752-14753.
https://psnet.ahrq.gov/issue/public-comment-period-extended-strategies-improve-patient-safety-d…
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psnet.ahrq.gov/node/44065/psn-pdf
July 16, 2015 - Nurses' use of computerized clinical guidelines to
improve patient safety in hospitals.
July 16, 2015
Hovde B, Jensen KH, Alexander GL, et al. Nurses' Use of Computerized Clinical Guidelines to Improve
Patient Safety in Hospitals. West J Nurs Res. 2015;37(7):877-98. doi:10.1177/0193945915577430.
https://psnet.ahrq…
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psnet.ahrq.gov/node/855099/psn-pdf
November 08, 2023 - Doctors wrestle with A.I. in patient care, citing lax
oversight.
November 8, 2023
Jewett C. New York Times. October 30, 2023
https://psnet.ahrq.gov/issue/doctors-wrestle-ai-patient-care-citing-lax-oversight
US Food and Drug Administration regulation and review is noted as having gaps in process that can affect
pa…