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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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 …
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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-…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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.…
  15. Psn-Pdf (pdf file)

    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…
  16. Psn-Pdf (pdf file)

    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. …
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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…

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