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psnet.ahrq.gov/node/39002/psn-pdf
January 03, 2017 - Engaging the patient as observer to promote hand
hygiene compliance in ambulatory care.
January 3, 2017
Bittle MJ, LaMarche S. Engaging the patient as observer to promote hand hygiene compliance in
ambulatory care. Jt Comm J Qual Patient Saf. 2009;35(10):519-25.
https://psnet.ahrq.gov/issue/engaging-patient-observ…
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psnet.ahrq.gov/node/47467/psn-pdf
January 21, 2019 - Application of electronic trigger tools to identify targets
for improving diagnostic safety.
January 21, 2019
Murphy DR, Meyer AN, Sittig DF, et al. Application of electronic trigger tools to identify targets for improving
diagnostic safety. BMJ Qual Saf. 2019;28(2):151-159. doi:10.1136/bmjqs-2018-008086.
https://…
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psnet.ahrq.gov/node/39419/psn-pdf
September 20, 2011 - Engaging patients as vigilant partners in safety: a
systematic review.
September 20, 2011
Schwappach DLB. Engaging patients as vigilant partners in safety: a systematic review. Med Care Res
Rev. 2010;67(2):119-148. doi:10.1177/1077558709342254.
https://psnet.ahrq.gov/issue/engaging-patients-vigilant-partners-safet…
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psnet.ahrq.gov/node/45375/psn-pdf
September 27, 2016 - Association of a web-based handoff tool with rates of
medical errors.
September 27, 2016
Mueller SK, Yoon CS, Schnipper JL. Association of a Web-Based Handoff Tool With Rates of Medical
Errors. JAMA Intern Med. 2016;176(9):1400-2. doi:10.1001/jamainternmed.2016.4258.
https://psnet.ahrq.gov/issue/association-web-ba…
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psnet.ahrq.gov/node/47547/psn-pdf
February 13, 2019 - Prevention of prescription opioid misuse and projected
overdose deaths in the United States.
February 13, 2019
Chen Q, Larochelle MR, Weaver DT, et al. Prevention of Prescription Opioid Misuse and Projected
Overdose Deaths in the United States. JAMA Netw Open. 2019;2(2):e187621.
doi:10.1001/jamanetworkopen.2018.76…
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psnet.ahrq.gov/node/40819/psn-pdf
January 07, 2015 - Multimodal system designed to reduce errors in recording
and administration of drugs in anaesthesia: prospective
randomised clinical evaluation.
January 7, 2015
Merry A, Webster CS, Hannam J, et al. Multimodal system designed to reduce errors in recording and
administration of drugs in anaesthesia: prospective ran…
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psnet.ahrq.gov/node/47727/psn-pdf
January 23, 2019 - Improving resident and fellow engagement in patient
safety through a graduate medical education incentive
program.
January 23, 2019
Turner DA, Bae J, Cheely G, et al. Improving Resident and Fellow Engagement in Patient Safety Through
a Graduate Medical Education Incentive Program. J Gen Intern Care. 2018;10(6):671…
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psnet.ahrq.gov/node/844044/psn-pdf
January 01, 2024 - Effect of contextual factors on the prevalence of
diagnostic errors among patients managed by physicians
of the same specialty: a single-centre retrospective
observational study.
February 8, 2023
Harada Y, Otaka Y, Katsukura S, et al. Effect of contextual factors on the prevalence of diagnostic errors
among patie…
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psnet.ahrq.gov/node/45979/psn-pdf
April 05, 2017 - Healthcare system-wide implementation of opioid-safety
guideline recommendations: the case of urine drug
screening and opioid-patient suicide- and overdose-
related events in the Veterans Health Administration.
April 5, 2017
Brennan PL, Del Re AC, Henderson PT, et al. Healthcare system-wide implementation of opioi…
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psnet.ahrq.gov/node/44750/psn-pdf
January 06, 2016 - Simulation in the executive suite: lessons learned for
building patient safety leadership.
January 6, 2016
Rosen MA, Goeschel CA, Che X-X, et al. Simulation in the Executive Suite: Lessons Learned for Building
Patient Safety Leadership. Simul Healthc. 2015;10(6):372-377.
https://psnet.ahrq.gov/issue/simulation-exe…
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psnet.ahrq.gov/node/44683/psn-pdf
June 21, 2016 - Physician spending and subsequent risk of malpractice
claims: observational study.
June 21, 2016
Jena AB, Schoemaker L, Bhattacharya J, et al. Physician spending and subsequent risk of malpractice
claims: observational study. BMJ. 2015;351:h5516. doi:10.1136/bmj.h5516.
https://psnet.ahrq.gov/issue/physician-spendi…
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psnet.ahrq.gov/node/40450/psn-pdf
December 21, 2014 - Unit-based care teams and the frequency and quality of
physician–nurse communications.
December 21, 2014
Gordon M, Melvin P, Graham DA, et al. Unit-based care teams and the frequency and quality of physician-
nurse communications. Arch Pediatr Adolesc Med. 2011;165(5):424-8. doi:10.1001/archpediatrics.2011.54.
htt…
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psnet.ahrq.gov/node/39499/psn-pdf
January 03, 2017 - Caring for our own: deploying a systemwide second
victim rapid response team.
January 3, 2017
Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a systemwide second victim rapid
response team. Jt Comm J Qual Saf. 2010;36(5):233-240.
https://psnet.ahrq.gov/issue/caring-our-own-deploying-systemwi…
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psnet.ahrq.gov/node/37874/psn-pdf
April 18, 2011 - Interprofessional handover and patient safety in
anaesthesia: observational study of handovers in the
recovery room.
April 18, 2011
Smith AF, Pope C, Goodwin D, et al. Interprofessional handover and patient safety in anaesthesia:
observational study of handovers in the recovery room. Br J Anaesth. 2008;101(3):332-…
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psnet.ahrq.gov/node/847544/psn-pdf
April 12, 2023 - A nationwide study of the "July Effect" concerning
postpartum hemorrhage and its risk factors at teaching
hospitals across the United States.
April 12, 2023
Shahin Z, Shah GH, Apenteng BA, et al. A nationwide study of the "July Effect" concerning postpartum
hemorrhage and its risk factors at teaching hospitals acr…
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psnet.ahrq.gov/node/866686/psn-pdf
September 11, 2024 - Impact of automated alerts on discharge opioid
overprescribing after general surgery.
September 11, 2024
Rizk E, Kaur N, Duong PY, et al. Impact of automated alerts on discharge opioid overprescribing after
general surgery. Am J Health Syst Pharm. 2024;81(24):1288-1296. doi:10.1093/ajhp/zxae185.
https://psnet.ahrq…
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psnet.ahrq.gov/node/43859/psn-pdf
May 28, 2015 - Point prevalence of surgical checklist use in Europe:
relationship with hospital mortality.
May 28, 2015
Jammer I, Ahmad T, Aldecoa C, et al. Point prevalence of surgical checklist use in Europe: relationship
with hospital mortality. Br J Anaesth. 2015;114(5):801-807. doi:10.1093/bja/aeu460.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/48085/psn-pdf
June 19, 2019 - A decade of preventing harm.
June 19, 2019
Woeltje KF, Olenski LK, Donatelli M, et al. A Decade of Preventing Harm. Jt Comm J Qual Patient Saf.
2019;45(7):480-486. doi:10.1016/j.jcjq.2019.04.007.
https://psnet.ahrq.gov/issue/decade-preventing-harm
Preventable patient safety problems continue to challenge health ca…
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psnet.ahrq.gov/node/39852/psn-pdf
February 10, 2015 - National costs of the medical liability system.
February 10, 2015
Mello MM, Chandra A, Gawande AA, et al. National costs of the medical liability system. Health Aff
(Millwood). 2010;29(9):1569-1577. doi:10.1377/hlthaff.2009.0807.
https://psnet.ahrq.gov/issue/national-costs-medical-liability-system
The role of medi…
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psnet.ahrq.gov/node/39873/psn-pdf
January 22, 2017 - A proactive risk avoidance system using failure mode and
effects analysis for "same-name" physician orders.
January 22, 2017
Tarpey K, Schaaf E, Lakhani U, et al. A proactive risk avoidance system using failure mode and effects
analysis for "same-name" physician orders. Jt Comm J Qual Patient Saf. 2010;36(10):461-7…