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psnet.ahrq.gov/node/50414/psn-pdf
September 04, 2019 - Rating the raters: an evaluation of publicly reported
hospital quality rating systems.
September 4, 2019
Bilimoria KY, Birkmeyer JD, Burstin H, et al. NEJM Catalyst. August 14, 2019.
https://psnet.ahrq.gov/issue/rating-raters-evaluation-publicly-reported-hospital-quality-rating-systems
Numerous publicly available …
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psnet.ahrq.gov/node/39895/psn-pdf
September 21, 2011 - Improving America's Hospitals: The Joint Commission's
Annual Report on Quality and Safety 2010.
September 21, 2011
Oakbrook Terrace, IL: The Joint Commission; September 2010.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-
safety-2010
In the fifth report on t…
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psnet.ahrq.gov/node/47756/psn-pdf
February 06, 2019 - Meltdown: Why Our Systems Fail and What We Can Do
About It.
February 6, 2019
Clearfield C, Tilcsik A. New York, NY: Penguin Press; 2018. ISBN: 978-0735222632.
https://psnet.ahrq.gov/issue/meltdown-why-our-systems-fail-and-what-we-can-do-about-it
Complex systems are prone to failure. This book provides a multi-indu…
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psnet.ahrq.gov/node/861279/psn-pdf
January 24, 2024 - Mistreatment in health care among women in Appalachia.
January 24, 2024
Alspaugh A, Swan LET, Auerbach SL, et al. Mistreatment in health care among women in Appalachia. Cult
Health Sex. 2023;25(12):1690-1706. doi:10.1080/13691058.2023.2176547.
https://psnet.ahrq.gov/issue/mistreatment-health-care-among-women-appala…
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psnet.ahrq.gov/node/38071/psn-pdf
February 15, 2011 - A multifaceted approach to safety: the synergistic
detection of adverse drug events in adult inpatients.
February 15, 2011
Ferranti JM, Horvath MM, Cozart H, et al. A Multifaceted Approach to Safety. J Patient Saf. 2008;4(3):184-
190. doi:10.1097/pts.0b013e318184a9d5.
https://psnet.ahrq.gov/issue/multifaceted-appr…
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psnet.ahrq.gov/node/46601/psn-pdf
January 25, 2018 - Night-time communication at Stanford University
Hospital: perceptions, reality and solutions.
January 25, 2018
Sun AJ, Wang L, Go M, et al. Night-time communication at Stanford University Hospital: perceptions, reality
and solutions. BMJ Qual Saf. 2018;27(2):156-162. doi:10.1136/bmjqs-2017-006727.
https://psnet.ah…
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psnet.ahrq.gov/node/45798/psn-pdf
February 01, 2017 - American College of Surgeons and Surgical Infection
Society: Surgical Site Infection Guidelines, 2016 Update.
February 1, 2017
Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical
Site Infection Guidelines, 2016 Update. J Am Coll Surg. 2017;224(1):59-74.
doi:10.…
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psnet.ahrq.gov/node/60235/psn-pdf
April 15, 2020 - Independent Mortality Review of Cardiac Surgery at St
George’s University Hospitals NHS Foundation Trust.
April 15, 2020
NHS Improvement. Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals
NHS Foundation Trust. NHS England. March 2020.
https://psnet.ahrq.gov/issue/independent-morta…
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psnet.ahrq.gov/node/43671/psn-pdf
December 10, 2014 - Reducing emergency department charting and ordering
errors with a room number watermark on the electronic
medical record display.
December 10, 2014
Yamamoto LG. Reducing emergency department charting and ordering errors with a room number
watermark on the electronic medical record display. Hawaii J Med Public Heal…
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psnet.ahrq.gov/node/859355/psn-pdf
December 20, 2023 - Systems-Based Approaches to Improve Patient Safety by
Improving Healthcare Worker Safety and Well-Being (R01
Clinical Trial Optional).
December 20, 2023
PA-24-093. Rockville, MD: Agency for Healthcare Research and Quality. December 5, 2023.
https://psnet.ahrq.gov/issue/systems-based-approaches-improve-patient-safe…
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psnet.ahrq.gov/node/34055/psn-pdf
March 07, 2005 - What is driving hospitals' patient-safety efforts?
March 7, 2005
Devers KJ, Pham HH, Liu G. What is driving hospitals' patient-safety efforts? Health Aff (Millwood).
2004;23(2):103-15.
https://psnet.ahrq.gov/issue/what-driving-hospitals-patient-safety-efforts
This study evaluated the role professionalism, regulati…
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psnet.ahrq.gov/node/850352/psn-pdf
June 14, 2023 - Stigmatizing language expressed towards individuals
with current or previous OUD who have pain and cancer:
a qualitative study.
June 14, 2023
Sedney CL, Dekeseredy P, Singh SA, et al. Stigmatizing language expressed towards individuals with
current or previous OUD who have pain and cancer: a qualitative study. J P…
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psnet.ahrq.gov/node/46045/psn-pdf
December 22, 2018 - Validating domains of patient contextual factors essential
to preventing contextual errors: a qualitative study
conducted at Chicago area Veterans Health
Administration sites.
December 22, 2018
Binns-Calvey AE, Malhiot A, Kostovich CT, et al. Validating Domains of Patient Contextual Factors
Essential to Preventin…
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psnet.ahrq.gov/node/854835/psn-pdf
October 25, 2023 - Improving patient safety by shifting power from health
professionals to patients.
October 25, 2023
BMJ. 2023(383):2219, 2278, 2319, 2331.
https://psnet.ahrq.gov/issue/improving-patient-safety-shifting-power-health-professionals-patients
This compendium of editorials and opinion pieces discuss “Martha’s Rule,” a ne…
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psnet.ahrq.gov/node/866408/psn-pdf
July 31, 2024 - Influences of leadership, organizational culture, and
hierarchy on raising concerns about patient deterioration:
a qualitative study.
July 31, 2024
Vehvilainen E, Charles A, Sainsbury J, et al. Influences of leadership, organizational culture, and hierarchy
on raising concerns about patient deterioration: a qualit…
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psnet.ahrq.gov/node/47839/psn-pdf
May 01, 2019 - Comparison of a prototype for indications-based
prescribing with 2 commercial prescribing systems.
May 1, 2019
Garabedian PM, Wright A, Newbury I, et al. Comparison of a Prototype for Indications-Based Prescribing
With 2 Commercial Prescribing Systems. JAMA Netw Open. 2019;2(3):e191514.
doi:10.1001/jamanetworkopen…
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psnet.ahrq.gov/node/46953/psn-pdf
September 12, 2018 - An integrative review exploring the perceptions of
patients and healthcare professionals towards patient
involvement in promoting hand hygiene compliance in the
hospital setting.
September 12, 2018
Alzyood M, Jackson D, Brooke J, et al. An integrative review exploring the perceptions of patients and
healthcare pr…
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psnet.ahrq.gov/node/72814/psn-pdf
March 10, 2021 - Implementing a human factors approach to RCA(2) :
tools, processes and strategies.
March 10, 2021
Wiegmann DA, Wood LJ, Solomon DB, et al. Implementing a human factors approach to RCA(2) : tools,
processes and strategies. J Healthc Risk Manag. 2021;41(1):31-46. doi:10.1002/jhrm.21454.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/42449/psn-pdf
July 31, 2013 - The epidemiology of malpractice claims in primary care: a
systematic review.
July 31, 2013
Wallace E, Lowry J, Smith SM, et al. The epidemiology of malpractice claims in primary care: a systematic
review. BMJ Open. 2013;3(7). doi:10.1136/bmjopen-2013-002929.
https://psnet.ahrq.gov/issue/epidemiology-malpractice-cl…
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psnet.ahrq.gov/node/848816/psn-pdf
May 10, 2023 - Racial bias in cesarean decision-making.
May 10, 2023
Edwards SE, Class QA, Ford CE, et al. Racial bias in cesarean decision-making. Am J Obstet Gynecol
MFM. 2023;5(5):100927. doi:10.1016/j.ajogmf.2023.100927.
https://psnet.ahrq.gov/issue/racial-bias-cesarean-decision-making
Racial bias negatively impacts maternal…