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psnet.ahrq.gov/node/854266/psn-pdf
October 04, 2023 - Smart Healthcare Safety.
October 4, 2023
Plymouth Meeting PA, ECRI. 2019-2023.
https://psnet.ahrq.gov/issue/smart-healthcare-safety
A wide variety of considerations must converge to inform an understanding of system vulnerabilities and
the application of strategies to address them. This series of webinars covers a…
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psnet.ahrq.gov/node/43015/psn-pdf
May 29, 2014 - Team-training in healthcare: a narrative synthesis of the
literature.
May 29, 2014
Weaver SJ, Dy SM, Rosen MA. Team-training in healthcare: a narrative synthesis of the literature. BMJ
Qual Saf. 2014;23(5):359-72. doi:10.1136/bmjqs-2013-001848.
https://psnet.ahrq.gov/issue/team-training-healthcare-narrative-synthe…
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psnet.ahrq.gov/node/866359/psn-pdf
June 01, 2022 - Diagnostic Safety Toolkit.
June 1, 2022
Diagnostic Safety Toolkit.
https://psnet.ahrq.gov/issue/diagnostic-safety-toolkit-0
Effective communication is critical as patients shift from one level of care to another as their diagnosis
evolves. This toolkit is designed to help academic medical centers initiate conversa…
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psnet.ahrq.gov/node/856641/psn-pdf
January 01, 2009 - WebAIRS Anesthesia Incident Reporting System.
January 1, 2009
Australian and New Zealand Tripartite Anaesthetic Data Committee.
https://psnet.ahrq.gov/issue/webairs-anesthesia-incident-reporting-system
Reporting errors in anesthesiology practice can motivate and inform safety improvement work. This website
serves …
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psnet.ahrq.gov/node/47696/psn-pdf
February 22, 2019 - Operating room fires.
February 22, 2019
Jones TS, Black IH, Robinson TN, et al. Operating Room Fires. Anesthesiology. 2019;130(3):492-501.
doi:10.1097/ALN.0000000000002598.
https://psnet.ahrq.gov/issue/operating-room-fires
Surgical fires, though uncommon, can result in serious harm. This review highlights three co…
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psnet.ahrq.gov/node/38885/psn-pdf
August 19, 2009 - Patient safety: Part II. Opportunities for improvement in
patient safety.
August 19, 2009
Elston DM, Stratman E, Johnson-Jahangir H, et al. Patient safety: Part II. Opportunities for improvement in
patient safety. J Am Acad Dermatol. 2009;61(2):193-205; quiz 206. doi:10.1016/j.jaad.2009.04.055.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/47144/psn-pdf
June 13, 2018 - Canadian Anesthesia Incident Reporting System.
June 13, 2018
Canadian Anaesthesiologists Society.
https://psnet.ahrq.gov/issue/canadian-anesthesia-incident-reporting-system
Reporting mistakes in anesthesiology practice can motivate and inform error reduction work. This website
provides a secure tool for submitting…
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psnet.ahrq.gov/node/38305/psn-pdf
January 15, 2009 - High-alert medications in the pediatric intensive care unit.
January 15, 2009
Franke HA, Woods D, Holl JL. High-alert medications in the pediatric intensive care unit. Pediatr Crit Care
Med. 2009;10(1):85-90. doi:10.1097/PCC.0b013e3181936ff8.
https://psnet.ahrq.gov/issue/high-alert-medications-pediatric-intensive-c…
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psnet.ahrq.gov/node/46557/psn-pdf
November 22, 2017 - Safe handover.
November 22, 2017
Merten H, van Galen LS, Wagner C. Safe handover. BMJ. 2017;359:j4328. doi:10.1136/bmj.j4328.
https://psnet.ahrq.gov/issue/safe-handover
Patient handovers between clinical teams are a common point of information exchange that can be
challenging to perform due to interruptions, produ…
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psnet.ahrq.gov/node/45086/psn-pdf
July 02, 2019 - Half-life of a printed handoff document.
July 2, 2019
Rosenbluth G, Jacolbia R, Milev D, et al. Half-life of a printed handoff document. BMJ Qual Saf.
2016;25(5):324-8. doi:10.1136/bmjqs-2015-004585.
https://psnet.ahrq.gov/issue/half-life-printed-handoff-document
Despite advances in handoff practices, printed sign…
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psnet.ahrq.gov/node/44502/psn-pdf
May 07, 2018 - Draft Guidelines for the Safe Communication of Electronic
Medication Information.
May 7, 2018
Institute for Safe Medication Practices. Acute Care Edition. August 27, 2015;2;1-3,6.
https://psnet.ahrq.gov/issue/draft-guidelines-safe-communication-electronic-medication-information
How electronic medication-related in…
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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…