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psnet.ahrq.gov/node/40067/psn-pdf
December 08, 2010 - Slowing down to stay out of trouble in the operating
room: remaining attentive in automaticity.
December 8, 2010
Moulton C-A, Regehr G, Lingard LA, et al. Slowing down to stay out of trouble in the operating room:
remaining attentive in automaticity. Acad Med. 2010;85(10):1571-7. doi:10.1097/ACM.0b013e3181f073dd.
…
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psnet.ahrq.gov/node/37920/psn-pdf
May 24, 2015 - Functional health literacy and understanding of
medications at discharge.
May 24, 2015
Maniaci MJ, Heckman MG, Dawson NL. Functional health literacy and understanding of medications at
discharge. Mayo Clin Proc. 2008;83(5):554-8. doi:10.4065/83.5.554.
https://psnet.ahrq.gov/issue/functional-health-literacy-and-und…
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-33
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:18-21.
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psnet.ahrq.gov/node/33593/psn-pdf
June 15, 2024 - Measurement is used for a variety of purposes: to evaluate the effectiveness of
safety interventions
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psnet.ahrq.gov/node/34638/psn-pdf
December 23, 2008 - What is accountability in health care?
December 23, 2008
Emanuel EJ, Emanuel LL. What is accountability in health care? Ann Intern Med. 1996;124(2):229-239.
https://psnet.ahrq.gov/issue/what-accountability-health-care
This perspective details the concepts surrounding “accountability” in health care. The discussion …
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psnet.ahrq.gov/primer/measurement-patient-safety
September 15, 2024 - Measurement is used for a variety of purposes: to evaluate the effectiveness of safety interventions,
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psnet.ahrq.gov/node/47921/psn-pdf
June 18, 2019 - Using incident reports to assess communication failures
and patient outcomes.
June 18, 2019
Umberfield E, Ghaferi AA, Krein SL, et al. Using Incident Reports to Assess Communication Failures and
Patient Outcomes. Jt Comm J Qual Patient Saf. 2019;45(6):406-413. doi:10.1016/j.jcjq.2019.02.006.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/44087/psn-pdf
November 16, 2015 - Teaching a 'good' ward round.
November 16, 2015
Powell N, Bruce CG, Redfern O. Teaching a 'good' ward round. Clin Med (Lond). 2015;15(2):135-138.
doi:10.7861/clinmedicine.15-2-135.
https://psnet.ahrq.gov/issue/teaching-good-ward-round
Ward rounds, while an important educational activity, may not receive the attent…
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psnet.ahrq.gov/node/43565/psn-pdf
March 22, 2016 - The role of failure mode and effects analysis in health
care.
March 22, 2016
Fibuch E, Ahmed A. The role of failure mode and effects analysis in health care. Physician Exec.
2014;40(4):28-32.
https://psnet.ahrq.gov/issue/role-failure-mode-and-effects-analysis-health-care
Failure mode and effects analysis (FMEA) h…
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psnet.ahrq.gov/node/44918/psn-pdf
April 13, 2016 - National Reporting and Learning System Research and
Development.
April 13, 2016
Mayer E, Flott K, Callahan R, Darzi A. London, UK: NIHR Imperial Patient Safety Translational Research
Centre; 2016.
https://psnet.ahrq.gov/issue/national-reporting-and-learning-system-research-and-development
Incident reporting has a…
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psnet.ahrq.gov/node/43647/psn-pdf
November 12, 2014 - Mid Staffordshire NHS Foundation Trust Quality Report.
November 12, 2014
Newcastle Upon Tyne, UK: Care Quality Commission; October 9, 2014.
https://psnet.ahrq.gov/issue/mid-staffordshire-nhs-foundation-trust-quality-report
The Mid Staffordshire Trust has been under much scrutiny in recent years. This report highlig…
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psnet.ahrq.gov/node/46380/psn-pdf
September 06, 2017 - What defines a high-performing health system: a
systematic review.
September 6, 2017
Ahluwalia SC, Damberg CL, Silverman M, et al. What Defines a High-Performing Health Care Delivery
System: A Systematic Review. Jt Comm J Qual Patient Saf. 2017;43(9):450-459.
doi:10.1016/j.jcjq.2017.03.010.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/45506/psn-pdf
November 30, 2016 - Is an indication-based prescribing system in our future?
November 30, 2016
ISMP Medication Safety Alert! Acute Care Edition. November 17, 2016;21:1-5.
https://psnet.ahrq.gov/issue/indication-based-prescribing-system-our-future
Health information technology has enhanced prescribers' ability to document the purpose o…
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psnet.ahrq.gov/glossary/handoffs-and-handovers
September 13, 2021 - Handoffs and Handovers
September 13, 2021
Anonymous (not verified)
See Primer . The process when one health care professional updates another on the status of one or more patients for the purpose of taking over their care. Typical examples involve a physician who has been on call overnight telling an incoming …
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psnet.ahrq.gov/issue/using-good-design-eliminate-medical-errors
December 09, 2020 - Newspaper/Magazine Article
Using good design to eliminate medical errors.
Citation Text:
Using good design to eliminate medical errors. Jaffe E.
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psnet.ahrq.gov/issue/what-medications-does-your-patient-take-enhancing-medication-safety-outpatient-setting
January 08, 2020 - Commentary
What medications does your patient take? Enhancing medication safety in the outpatient setting.
Citation Text:
What medications does your patient take? Enhancing medication safety in the outpatient setting. Institute for Healthcare Improvement; IHI
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psnet.ahrq.gov/node/45616/psn-pdf
November 27, 2017 - Education for the next frontier in patient safety: a
longitudinal resident curriculum on diagnostic error.
November 27, 2017
Ruedinger E, Olson M, Yee J, et al. Education for the Next Frontier in Patient Safety: A Longitudinal
Resident Curriculum on Diagnostic Error. Am J Med Qual. 2017;32(6):625-631.
doi:10.1177/…
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psnet.ahrq.gov/node/48098/psn-pdf
July 10, 2019 - How often do prescribers include indications in drug
orders? Analysis of 4 million outpatient prescriptions.
July 10, 2019
Salazar A, Karmiy SJ, Forsythe KJ, et al. How often do prescribers include indications in drug orders?
Analysis of 4 million outpatient prescriptions. Am J Health Syst Pharm. 2019;76(13):970-97…
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psnet.ahrq.gov/node/33923/psn-pdf
June 12, 2018 - The collapse of sensemaking in organizations: the Mann
Gulch disaster.
June 12, 2018
Weick KE. The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster. Admin Sci Q.
2006;38(4):628-652. doi:10.2307/2393339.
https://psnet.ahrq.gov/issue/collapse-sensemaking-organizations-mann-gulch-disaster
This artic…
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psnet.ahrq.gov/node/45448/psn-pdf
January 23, 2017 - Accuracy of laboratory data communication on ICU daily
rounds using an electronic health record.
January 23, 2017
Artis KA, Dyer E, Mohan V, et al. Accuracy of Laboratory Data Communication on ICU Daily Rounds Using
an Electronic Health Record. Crit Care Med. 2017;45(2):179-186. doi:10.1097/CCM.0000000000002060.
h…