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psnet.ahrq.gov/node/73663/psn-pdf
September 01, 2021 - Racial disparities in preventable adverse events attributed
to poor care coordination reported in a national study of
older US adults.
September 1, 2021
Pinheiro LC, Reshetnyak E, Safford MM, et al. Racial disparities in preventable adverse events attributed to
poor care coordination reported in a national study o…
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psnet.ahrq.gov/node/60055/psn-pdf
March 18, 2020 - A smartphone app designed to empower patients to
contribute toward safer surgical care: community-based
evaluation using a participatory approach.
March 18, 2020
Russ S, Latif Z, Hazell AL, et al. A Smartphone App Designed to Empower Patients to Contribute Toward
Safer Surgical Care: Community-Based Evaluation Usi…
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psnet.ahrq.gov/node/74201/psn-pdf
December 22, 2021 - Next of kin involvement in regulatory investigations of
adverse events that caused patient death: a process
evaluation.
December 22, 2021
Wiig S, Haraldseid-Driftland C, Tvete Zachrisen R, et al. J Patient Saf. 2021;17(8):e1707-
e1718.
https://psnet.ahrq.gov/issue/next-kin-involvement-regulatory-inves…
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psnet.ahrq.gov/node/844544/psn-pdf
February 15, 2023 - Involving patients and carers in patient safety in primary
care: a qualitative study of a co-designed patient safety
guide.
February 15, 2023
Morris RL, Giles SJ, Campbell S. Involving patients and carers in patient safety in primary care: a
qualitative study of a co?designed patient safety guide. Health Expect. 2…
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psnet.ahrq.gov/node/850917/psn-pdf
June 21, 2023 - Improving safety outcomes through medical error
reduction via virtual reality-based clinical skills training.
June 21, 2023
Kennedy GAL, Pedram S, Sanzone S. Improving safety outcomes through medical error reduction via
virtual reality-based clinical skills training. Safety Sci. 2023;165:106200. doi:10.1016/j.ssci.…
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psnet.ahrq.gov/node/847720/psn-pdf
April 19, 2023 - In situ simulation-based team training and its significance
for transfer of learning to clinical practice--a qualitative
focus group interview study of anaesthesia personnel.
April 19, 2023
Finstad AS, Aase I, Bjørshol CA, et al. In situ simulation-based team training and its significance for
transfer of learning …
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psnet.ahrq.gov/node/50573/psn-pdf
October 23, 2019 - Preventing patient harm via adverse event review: An
APSA survey regarding the role of morbidity and mortality
(M&M) conference.
October 23, 2019
Berman L, Ottosen M, Renaud E, et al. Preventing patient harm via adverse event review: An APSA survey
regarding the role of morbidity and mortality (M&M) conference. J …
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psnet.ahrq.gov/node/61004/psn-pdf
October 07, 2020 - National Nursing Home COVID Action Network.
October 7, 2020
Rockville, MD: Agency for Healthcare Research and Quality; September 2020.
https://psnet.ahrq.gov/issue/national-nursing-home-covid-action-network
Nursing home residents are especially vulnerable to COVID-19 due to their age, and communal living
condition…
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psnet.ahrq.gov/node/865532/psn-pdf
April 10, 2024 - Let us to the TWISST; Plan, Simulate, Study and Act.
April 10, 2024
Colman N, Hebbar KB. Let us to the TWISST; Plan, Simulate, Study and Act. Pediatr Qual Saf.
2023;8(4):e664. doi:10.1097/pq9.0000000000000664.
https://psnet.ahrq.gov/innovation/let-us-twisst-plan-simulate-study-and-act
In situ simulation can identi…
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psnet.ahrq.gov/issue/patient-safety-climate-psc-perceptions-frontline-staff-acute-care-hospitals-examining-role
March 28, 2012 - Study
Patient safety climate (PSC) perceptions of frontline staff in acute care hospitals: examining the role of ease of reporting, unit norms of openness, and participative leadership.
Citation Text:
Zaheer S, Ginsburg LR, Chuang Y-T, et al. Patient safety climate (PSC) perceptions of f…
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psnet.ahrq.gov/issue/characteristics-medication-errors-and-adverse-drug-events-hospitals-participating-california
July 13, 2010 - Study
Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.
Citation Text:
Takata GS, Taketomo CK, Waite S, et al. Characteristics of medication errors and adverse drug events in hospitals particip…
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psnet.ahrq.gov/issue/introduction-mobile-adverse-event-reporting-system-associated-participation-adverse-event
July 03, 2016 - Study
Introduction of a mobile adverse event reporting system is associated with participation in adverse event reporting.
Citation Text:
Rubin DS, Pesyna C, Jakubczyk S, et al. Introduction of a Mobile Adverse Event Reporting System Is Associated With Participation in Adverse Event Repo…
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psnet.ahrq.gov/node/837141/psn-pdf
May 18, 2022 - The effects of leadership curricula with and without
implicit bias training on graduate medical education: a
multicenter randomized trial.
May 18, 2022
Hansen M, Harrod T, Bahr N, et al. The effects of leadership curricula with and without implicit bias training
on graduate medical education: a multicenter randomi…
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psnet.ahrq.gov/node/39783/psn-pdf
August 25, 2010 - Ethics, oversight and quality improvement initiatives.
August 25, 2010
Taylor HA, Pronovost PJ, Sugarman J. Ethics, oversight and quality improvement initiatives. Quality and
Safety in Health Care. 2010;19(4). doi:10.1136/qshc.2009.038034.
https://psnet.ahrq.gov/issue/ethics-oversight-and-quality-improvement-initia…
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psnet.ahrq.gov/issue/identifying-organizational-cultures-promote-patient-safety
June 16, 2011 - Study
Identifying organizational cultures that promote patient safety.
Citation Text:
Singer SJ, Falwell A, Gaba DM, et al. Identifying organizational cultures that promote patient safety. Health Care Manag Rev. 2009;34(4):300-311. doi:10.1097/HMR.0b013e3181afc10c.
Copy Citation
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psnet.ahrq.gov/issue/patient-and-family-contributions-improve-diagnostic-process-through-ourdx-electronic-health
October 27, 2021 - Study
Patient and family contributions to improve the diagnostic process through the OurDX electronic health record tool: a mixed method analysis.
Citation Text:
Bell SK, Harcourt K, Dong J, et al. Patient and family contributions to improve the diagnostic process through the OurDX elect…
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psnet.ahrq.gov/node/846160/psn-pdf
March 15, 2023 - Critical care teamwork in the future: the role of
TeamSTEPPS in the COVID-19 pandemic and implications
for the future.
March 15, 2023
Terregino CA, Jagpal S, Parikh P, et al. Critical Care Teamwork in the Future: The Role of Critical care
teamwork in the future: the role of TeamSTEPPS in the COVID-19 pandemic and …
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psnet.ahrq.gov/node/837324/psn-pdf
July 08, 2022 - A Statewide Collaborative to Support Vaginal Birth and
Reduce Unnecessary Cesarean Deliveries
July 8, 2022
https://psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-
cesarean-deliveries
Summary
Started in response to rising maternal morbidity and mortality rates in …
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psnet.ahrq.gov/node/836841/psn-pdf
June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered
Nurses and Paramedics To Provide Home Visits to
Recently Discharged Patients at Highest Risk for Hospital
Readmission
April 7, 2022
https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-
paramedics-provide-home
Sum…
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psnet.ahrq.gov/node/42680/psn-pdf
October 30, 2013 - Developing a framework for nursing handover in the
emergency department: an individualised and systematic
approach.
October 30, 2013
Klim S, Kelly A-M, Kerr D, et al. Developing a framework for nursing handover in the emergency
department: an individualised and systematic approach. J Clin Nurs. 2013;22(15-16):2233…