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psnet.ahrq.gov/node/38561/psn-pdf
April 15, 2009 - Health-Care–Associated Infections in Hospitals:
Continuing Leadership Needed from HHS to Prioritize
Prevention Practices and Improve Data on These
Infections.
April 15, 2009
Subcommittee on Health Care, Committee on Finance, US Senate, Government Accountability Office,
GAO-09-516T (March 18, 2009)
https://psnet.…
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psnet.ahrq.gov/node/35391/psn-pdf
April 06, 2011 - Effectiveness of a graduate medical education program
for improving medical event reporting attitude and
behavior.
April 6, 2011
Coyle YM, Mercer SQ, Murphy-Cullen CL, et al. Effectiveness of a graduate medical education program for
improving medical event reporting attitude and behavior. Qual Saf Health Care. 2…
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psnet.ahrq.gov/node/39369/psn-pdf
March 17, 2010 - Paediatric nurses' understanding of the process and
procedure of double-checking medications.
March 17, 2010
Dickinson A, McCall E, Twomey B, et al. Paediatric nurses' understanding of the process and procedure of
double-checking medications. J Clin Nurs. 2010;19(5-6). doi:10.1111/j.1365-2702.2009.03130.x.
https:/…
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psnet.ahrq.gov/node/35657/psn-pdf
July 05, 2013 - Pharmacist Staffing and the Use of Technology in Small
Rural Hospitals: Implications for Medication Safety.
July 5, 2013
Casey MM, Moscovice I, Davidson G. Minneapolis, MN: Upper Midwest Rural Health Research Center;
2005.
https://psnet.ahrq.gov/issue/pharmacist-staffing-and-use-technology-small-rural-hospitals-im…
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psnet.ahrq.gov/node/43010/psn-pdf
March 19, 2014 - Why pediatricians fail to diagnose hypertension: a
multicenter survey.
March 19, 2014
Bijlsma MW, Blufpand HN, Kaspers GJL, et al. Why pediatricians fail to diagnose hypertension: a
multicenter survey. J Pediatr. 2014;164(1):173-177.e7. doi:10.1016/j.jpeds.2013.08.066.
https://psnet.ahrq.gov/issue/why-pediatrician…
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psnet.ahrq.gov/node/45006/psn-pdf
April 06, 2016 - Quality and Patient Safety.
April 6, 2016
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/quality-and-patient-safety
The Agency for Healthcare Research and Quality has provided access to patient safety research,
information, and tools for nearly two decades. This website offers a wide rang…
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psnet.ahrq.gov/node/46233/psn-pdf
September 24, 2017 - Cutting-edge efforts in surgical patient safety.
September 24, 2017
Varghese TK, Ghaferi AA. Cutting-edge Efforts in Surgical Patient Safety. JAMA Surg. 2017;152(8):719-
720. doi:10.1001/jamasurg.2017.0858.
https://psnet.ahrq.gov/issue/cutting-edge-efforts-surgical-patient-safety
Implementation science examines me…
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psnet.ahrq.gov/node/38339/psn-pdf
January 31, 2011 - Physician autonomy and informed decision making:
finding the balance for patient safety and quality.
January 31, 2011
Mathews SC, Pronovost P. Physician autonomy and informed decision making: finding the balance for
patient safety and quality. JAMA. 2008;300(24):2913-5. doi:10.1001/jama.2008.846.
https://psnet.ahr…
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psnet.ahrq.gov/node/37938/psn-pdf
July 23, 2008 - An integrative review of the current evidence on the
relationship between hand hygiene interventions and the
incidence of health care-associated infections.
July 23, 2008
Backman C, Zoutman DE, Marck PB. An integrative review of the current evidence on the relationship
between hand hygiene interventions and the in…
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psnet.ahrq.gov/node/47743/psn-pdf
February 22, 2019 - Assessing the performance of aging surgeons.
February 22, 2019
Katlic MR, Coleman JA, Russell MM. Assessing the Performance of Aging Surgeons. JAMA.
2019;321(5):449-450. doi:10.1001/jama.2018.22216.
https://psnet.ahrq.gov/issue/assessing-performance-aging-surgeons
High-risk industries like aviation employ policies…
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psnet.ahrq.gov/node/38258/psn-pdf
April 14, 2011 - How often do physicians review medication charts on
ward rounds?
April 14, 2011
Looi KL, Black PN. How often do physicians review medication charts on ward rounds? BMC Clin
Pharmacol. 2008;8:9. doi:10.1186/1472-6904-8-9.
https://psnet.ahrq.gov/issue/how-often-do-physicians-review-medication-charts-ward-rounds
Thi…
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psnet.ahrq.gov/node/39089/psn-pdf
November 11, 2009 - Blame culture and defensive medicine.
November 11, 2009
Catino M. Blame culture and defensive medicine. Cognition, Technology & Work. 2009;11(4).
doi:10.1007/s10111-009-0130-y.
https://psnet.ahrq.gov/issue/blame-culture-and-defensive-medicine
This study surveyed more than 300 Italian general practitioners and foun…
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psnet.ahrq.gov/node/843322/psn-pdf
February 01, 2023 - A deadly epidural, delivered by a doctor with a history of
mistakes.
February 1, 2023
Goldstein J. New York Times. January 23, 2023.
https://psnet.ahrq.gov/issue/deadly-epidural-delivered-doctor-history-mistakes
Active errors are evident when they occur, yet systemic weaknesses, if not addressed, allow them to rep…
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psnet.ahrq.gov/node/48166/psn-pdf
August 28, 2019 - Doctors can change opioid prescribing habits, but
progress comes in small doses.
August 28, 2019
Appleby J; Lucas E.
https://psnet.ahrq.gov/issue/doctors-can-change-opioid-prescribing-habits-progress-comes-small-doses
Efforts to reduce misuse of prescription opioids must draw from public health and behavioral stra…
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psnet.ahrq.gov/training-catalog/medicine-patient-safety-conference-2025
January 01, 2025 - Medicine Patient Safety Conference: 2025
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Organization:
Organization
George Washington University School of Medicine and Health Sciences
…
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psnet.ahrq.gov/node/40238/psn-pdf
February 23, 2011 - Feasibility of centre-based incident reporting in primary
healthcare: the SPIEGEL study.
February 23, 2011
Zwart DLM, Steerneman AHM, van Rensen ELJ, et al. Feasibility of centre-based incident reporting in
primary healthcare: the SPIEGEL study. BMJ Qual Saf. 2011;20(2):121-7.
doi:10.1136/bmjqs.2009.033472.
https…
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psnet.ahrq.gov/node/44623/psn-pdf
November 11, 2015 - Quality, Safety, and Noninterpretive Skills.
November 11, 2015
Kruskal JB, Kung JW, eds. Radiographics. 2015;35(6):1627-1848.
https://psnet.ahrq.gov/issue/quality-safety-and-noninterpretive-skills
Increased radiation exposure has emerged as a patient safety problem, with the potential to result in harm
for provide…
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psnet.ahrq.gov/node/42511/psn-pdf
February 06, 2014 - Ending disruptive behavior: staff nurse recommendations
to nurse educators.
February 6, 2014
Lux KM, Hutcheson JB, Peden AR. Ending disruptive behavior: staff nurse recommendations to nurse
educators. Nurse Educ Pract. 2014;14(1):37-42. doi:10.1016/j.nepr.2013.06.014.
https://psnet.ahrq.gov/issue/ending-disruptive…
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psnet.ahrq.gov/node/45431/psn-pdf
November 22, 2017 - ?Pediatric chest radiographs: common and less common
errors.
November 22, 2017
Menashe SJ, Iyer RS, Parisi MT, et al. Pediatric Chest Radiographs: Common and Less Common Errors.
AJR Am J Roentgenol. 2016;207(4):903-911. doi:10.2214/AJR.16.16449.
https://psnet.ahrq.gov/issue/pediatric-chest-radiographs-common-and-l…
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psnet.ahrq.gov/node/50643/psn-pdf
November 06, 2019 - Same Day Surgery in the US; Findings of Two Inaugural
Leapfrog Surveys 2019.
November 6, 2019
Washington DC: Leapfrog Group; 2019.
https://psnet.ahrq.gov/issue/same-day-surgery-us-findings-two-inaugural-leapfrog-surveys-2019
Ambulatory surgery centers (ASC) are established venues for surgical care despite lack of …