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psnet.ahrq.gov/node/74042/psn-pdf
November 03, 2021 - An Investigation into the Death of Baby J at University
Hospitals Bristol and Weston NHS Foundation Trust.
November 3, 2021
Manchester, UK: Parliamentary and Health Service Ombudsman; October 2021.
https://psnet.ahrq.gov/issue/investigation-death-baby-j-university-hospitals-bristol-and-weston-nhs-
foundation-trust…
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psnet.ahrq.gov/node/34715/psn-pdf
February 18, 2011 - Continuous improvement as an ideal in health care.
February 18, 2011
Berwick D. Continuous improvement as an ideal in health care. New Engl J Med. 1989;320(1):53-56.
https://psnet.ahrq.gov/issue/continuous-improvement-ideal-health-care
Two approaches to improving quality in health care are illustrated in this artic…
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psnet.ahrq.gov/node/42790/psn-pdf
December 04, 2013 - Patients do not always complain when they are
dissatisfied: implications for service quality and patient
safety.
December 4, 2013
Howard M, Fleming ML, Parker E. Patients do not always complain when they are dissatisfied: implications
for service quality and patient safety. J Patient Saf. 2013;9(4):224-31.
doi:10…
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psnet.ahrq.gov/node/42645/psn-pdf
October 09, 2013 - Eliminating CAUTI: Interim Data Report: A National
Patient Safety Imperative.
October 9, 2013
Rockville, MD: Agency for Healthcare Research and Quality; July 2013. AHRQ Publication No. 13-0071-
EF.
https://psnet.ahrq.gov/issue/eliminating-cauti-interim-data-report-national-patient-safety-imperative
This report pr…
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psnet.ahrq.gov/node/867632/psn-pdf
February 26, 2025 - Instruments for patient safety assessment: a scoping
review.
February 26, 2025
Nunes E, Sirtoli F, Lima E, et al. Instruments for patient safety assessment: a scoping review. Healthcare.
2024;12(20):2075. doi:10.3390/healthcare12202075.
https://psnet.ahrq.gov/issue/instruments-patient-safety-assessment-scoping-rev…
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psnet.ahrq.gov/node/60963/psn-pdf
September 30, 2020 - Organisation and characteristics of out-of-hours primary
care during a COVID-19 outbreak: a real-time
observational study.
September 30, 2020
Morreel S, Philips H, Verhoeven V. Organisation and characteristics of out-of-hours primary care during a
COVID-19 outbreak: a real-time observational study. PLoS One. 2020;…
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psnet.ahrq.gov/node/34730/psn-pdf
October 29, 2013 - Medication Errors. 2nd ed.
October 29, 2013
Cohen MR, ed. Washington DC: American Pharmacists Association; 2007.
https://psnet.ahrq.gov/issue/medication-errors-2nd-ed
Cohen, executive director of the Institute for Safe Medication Practices (ISMP), combined 25 years of
experience as a leader in medication safety wi…
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psnet.ahrq.gov/node/44794/psn-pdf
May 21, 2019 - Medical Device Use Error: Root Cause Analysis.
May 21, 2019
Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790.
https://psnet.ahrq.gov/issue/medical-device-use-error-root-cause-analysis
Applying human factors engineering to examine mistakes associated with medical device use can lead …
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psnet.ahrq.gov/node/73922/psn-pdf
October 06, 2021 - Leading causes of anesthesia-related liability claims in
ambulatory surgery centers.
October 6, 2021
Ranum D, Beverly A, Shapiro FE, et al. Leading causes of anesthesia-related liability claims in ambulatory
surgery centers. J Patient Saf. 2021;17(7):513-521. doi:10.1097/pts.0000000000000431.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/46019/psn-pdf
April 26, 2017 - Certified registered nurse anesthetist perceptions of
factors impacting patient safety.
April 26, 2017
McMullan SP, Thomas-Hawkins C, Shirey MR. Certified Registered Nurse Anesthetist Perceptions of
Factors Impacting Patient Safety. Nurs Adm Q. 2017;41(1):56-69.
https://psnet.ahrq.gov/issue/certified-registered-nu…
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psnet.ahrq.gov/node/37525/psn-pdf
June 14, 2011 - Recommended guidelines for monitoring, reporting, and
conducting research on medical emergency team,
outreach, and rapid response systems: an Utstein-style
scientific statement.
June 14, 2011
Peberdy MA, Cretikos MA, Abella BS, et al. Recommended Guidelines for Monitoring, Reporting, and
Conducting Research on Me…
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psnet.ahrq.gov/node/852286/psn-pdf
August 09, 2023 - Guidelines on Human Factors in Critical Situations 2023.
August 9, 2023
Bijok B, Jaulin F, Picard J, et al. Guidelines on human factors in critical situations 2023. Anaesth Crit Care
Pain Med. 2023;42(4):101262. doi:10.1016/j.accpm.2023.101262.
https://psnet.ahrq.gov/issue/guidelines-human-factors-critical-situatio…
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psnet.ahrq.gov/node/838025/psn-pdf
September 07, 2022 - Opportunities to mine EHRs for malpractice risk
management and patient safety.
September 7, 2022
Adler-Milstein J, Sarkar U, Wachter RM. Opportunities to mine EHRs for malpractice risk management and
patient safety. J Patient Saf Risk Manag. 2022;27(4):160-162. doi:10.1177/25160435221097422.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/50554/psn-pdf
October 16, 2019 - Adverse events in the operating room: definitions,
prevalence, and characteristics. A systematic review.
October 16, 2019
Jung JJ, Elfassy J, Jüni P, et al. Adverse Events in the Operating Room: Definitions, Prevalence, and
Characteristics. A Systematic Review. World J Surg. 2019;43(10):2379-2392. doi:10.1007/s0026…
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psnet.ahrq.gov/node/863221/psn-pdf
February 28, 2024 - Using artificial intelligence to improve primary care for
patients and clinicians.
February 28, 2024
Sarkar U, Bates DW. Using artificial intelligence to improve primary care for patients and clinicians. JAMA
Intern Med. 2024;184(4):343-344. doi:10.1001/jamainternmed.2023.7965.
https://psnet.ahrq.gov/issue/using-a…
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psnet.ahrq.gov/node/74016/psn-pdf
October 27, 2021 - Malnutrition in Hospitalized Adults: A Systematic Review.
October 27, 2021
Uhl S, Siddique SM, McKeever L, et al. Rockville, MD: Agency for Healthcare Research and Quality;
October 2021. AHRQ Publication No. 21(22)-EHC035.
https://psnet.ahrq.gov/issue/malnutrition-hospitalized-adults-systematic-review
Patien…
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psnet.ahrq.gov/node/60665/psn-pdf
July 08, 2020 - Response of practicing chiropractors during the early
phase of the COVID-19 pandemic: a descriptive report.
July 8, 2020
Johnson CD, Green BN, Konarski-Hart KK, et al. Response of Practicing Chiropractors during the Early
Phase of the COVID-19 Pandemic: A Descriptive Report. J Manipulative Physiol Ther. 2020;43(5):…
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psnet.ahrq.gov/node/60631/psn-pdf
June 24, 2020 - Special report: COVID deepens the other opioid crisis - a
shortage of hospital painkillers.
June 24, 2020
Girion L, Levine D, Respaut R. Special report: COVID deepens the other opioid crisis - a shortage of
hospital painkillers. Reuters. 2020;June 9.
https://psnet.ahrq.gov/issue/special-report-covid-deepens-other-…
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psnet.ahrq.gov/node/848383/psn-pdf
May 03, 2023 - Burnout in Primary Care: Assessing and Addressing It in
Your Practice.
May 3, 2023
Gerteis J, Booker C, Brach C, et al. Rockville, MD: Agency for Healthcare Research and Quality;
February 2023. AHRQ Publication No. 23-0025.
https://psnet.ahrq.gov/issue/burnout-primary-care-assessing-and-addressing-it-your-pr…
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psnet.ahrq.gov/node/865346/psn-pdf
March 27, 2024 - RaDonda Vaught says some system practices contributed
to fatal mistake.
March 27, 2024
Clark C. MedPage Today. March 14, 2024.
https://psnet.ahrq.gov/issue/vaught-says-some-system-practices-contributed-fatal-mistake
Stories from clinicians involved in errors provide unique insights into both the human an…