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psnet.ahrq.gov/node/866317/psn-pdf
July 17, 2024 - BONE break: a hot debrief tool to reduce second victim
syndrome for nurses.
July 17, 2024
Hess A, Flicek T, Watral AT, et al. BONE break: a hot debrief tool to reduce second victim syndrome for
nurses. Jt Comm J Qual Patient Saf. 2024;50(9):673-677. doi:10.1016/j.jcjq.2024.05.005.
https://psnet.ahrq.gov/issue/bone…
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psnet.ahrq.gov/node/47349/psn-pdf
January 30, 2019 - Relationship of staff information sharing and advice
networks to patient safety outcomes.
January 30, 2019
Brewer BB, Carley KM, Benham-Hutchins MM, et al. Relationship of Staff Information Sharing and Advice
Networks to Patient Safety Outcomes. J Nurs Adm. 2018;48(9):437-444.
doi:10.1097/NNA.0000000000000646.
ht…
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psnet.ahrq.gov/node/41068/psn-pdf
September 29, 2017 - A review of verbal order policies in acute care hospitals.
September 29, 2017
Wakefield DS, Wakefield BJ, Despins L, et al. A review of verbal order policies in acute care hospitals. Jt
Comm J Qual Patient Saf. 2012;38(1):24-33.
https://psnet.ahrq.gov/issue/review-verbal-order-policies-acute-care-hospitals
Verbal …
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psnet.ahrq.gov/node/47890/psn-pdf
June 15, 2019 - Systems engineering and human factors support of a
system of novel EHR-integrated tools to prevent harm in
the hospital.
June 15, 2019
Dalal A, Fuller T, Garabedian P, et al. Systems engineering and human factors support of a system of
novel EHR-integrated tools to prevent harm in the hospital. J Am Med Inform Ass…
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psnet.ahrq.gov/node/60360/psn-pdf
May 20, 2020 - Medicare Part D Beneficiaries at Serious Risk of Opioid
Misuse or Overdose: A Closer Look.
May 20, 2020
HHS OIG Data Brief. Washington DC; Office of the Inspector General: May 4, 2020. Report number OEI-
02-19-00130.
https://psnet.ahrq.gov/issue/medicare-part-d-beneficiaries-serious-risk-opioid-misuse-or-overdose-…
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psnet.ahrq.gov/node/866518/psn-pdf
January 01, 2025 - Hospital rating organizations' quality and patient safety
scores: analysis of result discrepancies.
August 14, 2024
Badr S, Nahle T, Rahman S, et al. Hospital rating organizations' quality and patient safety scores: analysis
of result discrepancies. J Gen Intern Med. 2025;40(3):525-531. doi:10.1007/s11606-024-08950…
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psnet.ahrq.gov/node/46728/psn-pdf
March 27, 2018 - Near-miss event analysis enhances the barcode
medication administration process.
March 27, 2018
Magee MC; Miller K; Patzek D; Madera C; Michalek C; Shetterly M.
https://psnet.ahrq.gov/issue/near-miss-event-analysis-enhances-barcode-medication-administration-
process
Near misses provide unique opportunities to ide…
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psnet.ahrq.gov/node/45472/psn-pdf
September 29, 2017 - Declines in opioid prescribing after a private insurer
policy change—Massachusetts, 2011–2015.
September 29, 2017
García MC, Dodek AB, Kowalski T, et al. Declines in Opioid Prescribing After a Private Insurer Policy
Change - Massachusetts, 2011-2015. MMWR Morb Mortal Wkly Rep. 2016;65(41):1125-1131.
doi:10.15585/m…
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psnet.ahrq.gov/node/34893/psn-pdf
February 26, 2009 - The incidence of adverse drug events in two large
academic long-term care facilities.
February 26, 2009
Gurwitz JH, Field TS, Judge J, et al. The incidence of adverse drug events in two large academic long-term
care facilities. Am J Med. 2005;118(3). doi:10.1016/j.amjmed.2004.09.018.
https://psnet.ahrq.gov/issue/i…
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psnet.ahrq.gov/node/866637/psn-pdf
September 04, 2024 - Impact of rounding checklists on the outcomes of
patients admitted to ICUs: a systematic review and meta-
analysis.
September 4, 2024
MacKinnon KM, Seshadri S, Mailman JF, et al. Impact of rounding checklists on the outcomes of patients
admitted to ICUs: a systematic review and meta-analysis. Crit Care Explor. 202…
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psnet.ahrq.gov/node/44162/psn-pdf
May 27, 2015 - Computerised clinical decision support systems to
improve medication safety in long-term care homes: a
systematic review.
May 27, 2015
Marasinghe KM. Computerised clinical decision support systems to improve medication safety in long-term
care homes: a systematic review. BMJ Open. 2015;5(5):e006539. doi:10.1136/bm…
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psnet.ahrq.gov/node/47191/psn-pdf
December 21, 2018 - Barriers and facilitators to implementing a process to
enable parent escalation of care for the deteriorating child
in hospital.
December 21, 2018
Gill FJ, Leslie GD, Marshall AP. Barriers and facilitators to implementing a process to enable parent
escalation of care for the deteriorating child in hospital. Health…
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psnet.ahrq.gov/node/36539/psn-pdf
March 03, 2011 - Sensitivity of routine system for reporting patient safety
incidents in an NHS hospital: retrospective patient case
note review.
March 3, 2011
Sari AB-A, Sheldon T, Cracknell A, et al. Sensitivity of routine system for reporting patient safety incidents
in an NHS hospital: retrospective patient case note review. B…
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psnet.ahrq.gov/node/74184/psn-pdf
May 05, 2017 - Systematic review of the impact of physician implicit
racial bias on clinical decision making.
May 5, 2017
Dehon E, Weiss N, Jones J, et al. Systematic review of the impact of physician implicit racial bias on
clinical decision making. Acad Emerg Med. 2017;24(8):895-904. doi:10.1111/acem.13214.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/862601/psn-pdf
February 14, 2024 - Why simulation matters: a systematic review on medical
errors occurring during simulated health care.
February 14, 2024
Bokka L, Ciuffo F, Clapper TC. Why simulation matters: a systematic review on medical errors occurring
during simulated health care. J Patient Saf. 2024;20(2):110-118. doi:10.1097/pts.000000000000…
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psnet.ahrq.gov/node/45692/psn-pdf
January 01, 2020 - A patient reported approach to identify medical errors and
improve patient safety in the emergency department.
November 23, 2016
Glickman SW, Mehrotra A, Shea CM, et al. A Patient Reported Approach to Identify Medical Errors and
Improve Patient Safety in the Emergency Department. J Patient Saf. 2020;16(3):211-215.
…
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psnet.ahrq.gov/node/73220/psn-pdf
May 05, 2021 - Identifying barriers to and opportunities for telehealth
implementation amidst the COVID-19 pandemic by using
a human factors approach: a leap into the future of health
care delivery?
May 5, 2021
Zhang T, Mosier J, Subbian V. Identifying barriers to and opportunities for telehealth implementation amidst
the COVID…
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psnet.ahrq.gov/node/843079/psn-pdf
January 25, 2023 - Electronic health record use issues and diagnostic error:
a scoping review and framework.
January 25, 2023
Dixit RA, Boxley CL, Samuel S, et al. Electronic health record use issues and diagnostic error: a scoping
review and framework. J Patient Saf. 2023;19(1):e25-e30. doi:10.1097/pts.0000000000001081.
https://psn…
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psnet.ahrq.gov/node/854251/psn-pdf
October 04, 2023 - A scoping review exploring the confidence of healthcare
professionals in assessing all skin tones.
October 4, 2023
Harrison J. A scoping review exploring the confidence of healthcare professionals in assessing all skin
tones. Br Paramed J. 2023;8(2):18-28. doi:10.29045/14784726.2023.9.8.2.18.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/849600/psn-pdf
May 31, 2023 - Danger in discharge summaries: abbreviations create
confusion for both author and recipient.
May 31, 2023
Coghlan A, Turner S, Coverdale S. Danger in discharge summaries: abbreviations create confusion for
both author and recipient. Intern Med J. 2023;53(4):550-558. doi:10.1111/imj.15582.
https://psnet.ahrq.gov/is…