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psnet.ahrq.gov/node/838625/psn-pdf
October 19, 2022 - Improving communication and response to clinical
deterioration to increase patient safety in the intensive
care unit.
October 19, 2022
Liu SI, Shikar M, Gante E, et al. Improving communication and response to clinical deterioration to increase
patient safety in the intensive care unit. Crit Care Nurse. 2022;42(5):…
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psnet.ahrq.gov/node/47846/psn-pdf
March 06, 2019 - Assessment of the FDA Risk Evaluation and Mitigation
Strategy for transmucosal immediate-release fentanyl
products.
March 6, 2019
Rollman JE, Heyward J, Olson L, et al. Assessment of the FDA Risk Evaluation and Mitigation Strategy for
Transmucosal Immediate-Release Fentanyl Products. JAMA. 2019;321(7):676-685.
do…
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psnet.ahrq.gov/node/34070/psn-pdf
February 18, 2011 - Effect of reducing interns' work hours on serious medical
errors in intensive care units.
February 18, 2011
Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical
errors in intensive care units. N Engl J Med. 2004;351(18):1838-48.
https://psnet.ahrq.gov/issue/effec…
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psnet.ahrq.gov/node/38069/psn-pdf
March 10, 2011 - Evaluating clinical decision support systems: monitoring
CPOE order check override rates in the Department of
Veterans Affairs' computerized patient record system.
March 10, 2011
Lin C-P, Payne TH, Nichol P, et al. Evaluating clinical decision support systems: monitoring CPOE order
check override rates in the Depa…
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psnet.ahrq.gov/node/866860/psn-pdf
October 02, 2024 - Motivation for patient engagement in patient safety: a
multi-perspective, explorative survey.
October 2, 2024
Raab C, Gambashidze N, Brust L, et al. Motivation for patient engagement in patient safety: a multi-
perspective, explorative survey. BMC Health Serv Res. 2024;24(1):1052. doi:10.1186/s12913-024-11495-
x.
…
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psnet.ahrq.gov/node/35647/psn-pdf
June 25, 2010 - Nurse staffing in hospitals: is there a business case for
quality?
June 25, 2010
Needleman J, Buerhaus P, Stewart M, et al. Nurse staffing in hospitals: is there a business case for
quality? Health Aff (Millwood). 2006;25(1):204-11.
https://psnet.ahrq.gov/issue/nurse-staffing-hospitals-there-business-case-quality
…
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psnet.ahrq.gov/node/72799/psn-pdf
March 03, 2021 - Measuring and improving diagnostic safety in primary
care: addressing the “twin” pandemics of diagnostic error
and clinician burnout.
March 3, 2021
Olson APJ, Linzer M, Schiff GD. Measuring and Improving Diagnostic Safety in Primary Care: Addressing
the “Twin” Pandemics of Diagnostic Error and Clinician Burnout. J…
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psnet.ahrq.gov/node/60725/psn-pdf
July 29, 2020 - The tradeoffs between safety and alert fatigue: data from
a national evaluation of hospital medication-related
clinical decision support.
July 29, 2020
Co Z, Holmgren AJ, Classen DC, et al. The tradeoffs between safety and alert fatigue: data from a national
evaluation of hospital medication-related clinical decis…
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psnet.ahrq.gov/node/72475/psn-pdf
November 18, 2020 - Omissions of care in nursing homes: a uniform definition
for research and quality improvement.
November 18, 2020
Mangrum R, Stewart MD, Gifford DR, et al. Omissions of care in nursing homes: a uniform definition for
research and quality improvement. J Am Med Dir Assoc. 2020;21(11):1587-1591.e2.
doi:10.1016/j.jamda…
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psnet.ahrq.gov/node/73601/psn-pdf
August 18, 2021 - From implementation to sustainment: a large-scale
adverse event disclosure support program generated
through embedded research in the Veterans Health
Administration.
August 18, 2021
Elwy AR, Maguire EM, McCullough M, et al. From implementation to sustainment: a large-scale adverse
event disclosure support program…
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psnet.ahrq.gov/node/47680/psn-pdf
January 16, 2019 - Perioperative medication errors: uncovering risk from
behind the drapes.
January 16, 2019
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. 2018;15(4):1-17.
https://psnet.ahrq.gov/issue/perioperative-medication-errors-uncovering-risk-behind-drapes
The operating room environment harbors particular pat…
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psnet.ahrq.gov/node/836749/psn-pdf
March 16, 2022 - Comparison of a focused family cancer history
questionnaire to family history documentation in the
electronic medical record.
March 16, 2022
Clift K, Macklin-Mantia S, Barnhorst M, et al. Comparison of a focused family cancer history questionnaire
to family history documentation in the electronic medical record. J…
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psnet.ahrq.gov/node/72790/psn-pdf
March 03, 2021 - Parent engagement in perinatal mortality reviews: an
online survey of clinicians from six high-income
countries.
March 3, 2021
Boyle FM, Horey D, Siassakos D, et al. Parent engagement in perinatal mortality reviews: an online survey
of clinicians from six high?income countries. BJOG. 2020;128(4):696-703. doi:10.11…
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psnet.ahrq.gov/node/60297/psn-pdf
January 01, 2021 - A call for the application of patient safety culture in
medical humanitarian action: a literature review.
May 6, 2020
Biquet J-M, Schopper D, Sprumont D, et al. A call for the application of patient safety culture in medical
humanitarian action: a literature review. J Patient Saf. 2021;17(8):e1732-e1737.
doi:10.10…
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psnet.ahrq.gov/node/864848/psn-pdf
March 20, 2024 - An mHealth design to promote medication safety in
children with medical complexity.
March 20, 2024
Jolliff A, Coller RJ, Kearney H, et al. An mHealth design to promote medication safety in children with
medical complexity. Appl Clin Inform. 2024;15(1):45-54. doi:10.1055/a-2214-8000.
https://psnet.ahrq.gov/issue/mh…
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psnet.ahrq.gov/node/45335/psn-pdf
August 10, 2016 - The Feasibility of Determining the Effectiveness and Cost-
effectiveness of Medication Organisation Devices
Compared with Usual Care for Older People in a
Community Setting: Systematic Review, Stakeholder
Focus Groups and Feasibility RCT.
August 10, 2016
Bhattacharya D, Aldus CF, Barton G, et al. Health Tech…
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psnet.ahrq.gov/node/861767/psn-pdf
January 31, 2024 - Health literacy-informed communication to reduce
discharge medication errors in hospitalized children: a
randomized clinical trial.
January 31, 2024
Carroll AR, Johnson JA, Stassun JC, et al. Health literacy-informed communication to reduce discharge
medication errors in hospitalized children: a randomized clinica…
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psnet.ahrq.gov/node/46370/psn-pdf
November 08, 2017 - Standard admission order sets promote ordering of
unnecessary investigations: a quasi-randomised
evaluation in a simulated setting.
November 8, 2017
Leis B, Frost A, Bryce R, et al. Standard admission order sets promote ordering of unnecessary
investigations: a quasi-randomised evaluation in a simulated setting. B…
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psnet.ahrq.gov/node/847719/psn-pdf
April 19, 2023 - Person-first treatment strategies: weight bias and impact
on mental health of people living with obesity.
April 19, 2023
Crowley N. Person-first treatment strategies: weight bias and impact on mental health of people living with
obesity. Prim Care. 2023;50(1):89-101. doi:10.1016/j.pop.2022.10.002.
https://psnet.ah…
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psnet.ahrq.gov/node/47535/psn-pdf
November 07, 2018 - Gosport War Memorial Hospital. The Report of the
Gosport Independent Panel.
November 7, 2018
Gosport Independent Panel. London, England: Crown Copyright; 2018. ISBN: 9781528604062.
https://psnet.ahrq.gov/issue/gosport-war-memorial-hospital-report-gosport-independent-panel
Organizational culture influences how comf…