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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72857/psn-pdf
    March 17, 2021 - Results and lessons from a hospital-wide initiative incentivised by delivery system reform to improve infection prevention and sepsis care. March 17, 2021 Sreeramoju P, Voy-Hatter K, White C, et al. Results and lessons from a hospital-wide initiative incentivised by delivery system reform to improve infection prev…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46325/psn-pdf
    November 30, 2018 - Physician Burnout. November 30, 2018 Rockville, MD: Agency for Healthcare Research and Quality; July 2017. AHRQ Publication No. 17-M018-1- EF. https://psnet.ahrq.gov/issue/physician-burnout Clinician burnout can affect patient safety. This report highlights AHRQ-supported research to examine burnout in health car…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865483/psn-pdf
    April 03, 2024 - Risks in the analogue and digitally-supported medication process and potential solutions to increase patient safety in the hospital: a mixed methods study. April 3, 2024 Kopanz J, Lichtenegger K, Schwarz CM, et al. Risks in the analogue and digitally-supported medication process and potential solutions to increase…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848360/psn-pdf
    May 03, 2023 - Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic error (SPADE): comparison groups to maximize SPADE validity. May 3, 2023 Liberman AL, Wang Z, Zhu Y, et al. Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852751/psn-pdf
    August 23, 2023 - Automated search methods for identifying wrong patient order entry-a scoping review. August 23, 2023 Garrod M, Fox A, Rutter P. Automated search methods for identifying wrong patient order entry—a scoping review. JAMIA Open. 2023;6(3):ooad057. doi:10.1093/jamiaopen/ooad057. https://psnet.ahrq.gov/issue/automated-s…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842419/psn-pdf
    January 11, 2023 - Balancing safety, comfort, and fall risk: an intervention to limit opioid and benzodiazepine prescriptions for geriatric patients. January 11, 2023 Bloomer A, Wally M, Bailey G, et al. Balancing safety, comfort, and fall risk: an intervention to limit opioid and benzodiazepine prescriptions for geriatric patients.…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47834/psn-pdf
    February 27, 2019 - Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals. February 27, 2019 Rhee C, Jones TM, Hamad Y, et al. Prevalence, Underlying Causes, and Preventability of Sepsis- Associated Mortality in US Acute Care Hospitals. JAMA Netw Open. 2019;2(2):e187571. doi:10.10…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46124/psn-pdf
    April 17, 2018 - Improving the safety of health information technology requires shared responsibility: it is time we all step up. April 17, 2018 Sittig DF, Belmont E, Singh H. Improving the safety of health information technology requires shared responsibility: It is time we all step up. Healthc (Amst). 2017;6(1):7-12. doi:10.1016/…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849317/psn-pdf
    May 24, 2023 - Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure injuries. May 24, 2023 Armstrong AA. Implementing an electronic root cause analysis reporting system to decrease hospital- acquired pressure injuries. J Healthc Qual. 2023;45(3):125-132. doi:10.1097/jhq.0000000000…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837589/psn-pdf
    June 29, 2022 - Monitoring preventable adverse events and near misses: number and type identified differ depending on method used. June 29, 2022 Isaksson S, Schwarz A, Rusner M, et al. Monitoring preventable adverse events and near misses: number and type identified differ depending on method used. J Patient Saf. 2022;18(4):325-3…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47942/psn-pdf
    July 01, 2019 - Responding to health information technology reported safety events: insights from patient safety event reports. July 1, 2019 Adams KT, Kim TC, Fong A, et al. J Patient Saf Risk Manag. 2019;24:118–124. https://psnet.ahrq.gov/issue/responding-health-information-technology-reported-safety-events-insights- patient-saf…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866407/psn-pdf
    July 31, 2024 - Effect of digital tools to promote hospital quality and safety on adverse events after discharge. July 31, 2024 Vasudevan A, Plombon S, Piniella N, et al. Effect of digital tools to promote hospital quality and safety on adverse events after discharge. J Am Med Inform Assoc. 2024;31(10):2304-2314. doi:10.1093/jami…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867225/psn-pdf
    December 04, 2024 - Characterization of interventions to reduce the frequency of critical medication doses missed or delayed during perioperative and unit-to-unit patient transfers. December 4, 2024 Cole E, Duncan R, Grucz T, et al. Characterization of interventions to reduce the frequency of critical medication doses missed or delay…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38505/psn-pdf
    February 10, 2015 - Health information technology and patient safety: evidence from panel data. February 10, 2015 Parente ST, McCullough JS. Health information technology and patient safety: evidence from panel data. Health Aff (Millwood). 2009;28(2):357-360. doi:10.1377/hlthaff.28.2.357. https://psnet.ahrq.gov/issue/health-informati…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866517/psn-pdf
    August 14, 2024 - Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. August 14, 2024 Aikens RC, Chen JH, Baiocchi M, et al. Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. Med Decis Making. 2024;44(5):481-496. doi:10.1177/0272989x241248612. https://p…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43309/psn-pdf
    August 02, 2015 - Wrong-side thoracentesis: lessons learned from root cause analysis. August 2, 2015 Miller K, Mims M, Paull DE, et al. Wrong-side thoracentesis: lessons learned from root cause analysis. JAMA Surg. 2014;149(8):774-9. doi:10.1001/jamasurg.2014.146. https://psnet.ahrq.gov/issue/wrong-side-thoracentesis-lessons-learne…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47198/psn-pdf
    August 22, 2018 - Health IT Safe Practices for Closing the Loop. August 22, 2018 Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI; August 2018. https://psnet.ahrq.gov/issue/health-it-safe-practices-closing-loop Inadequate follow-up of test results can contribute to missed and delayed diagnoses. Developing optimal…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846442/psn-pdf
    March 22, 2023 - Heatwaves, hospitals and health system resilience in England: a qualitative assessment of frontline perspectives from the hot summer of 2019. March 22, 2023 Brooks K, Landeg O, Kovats S, et al. Heatwaves, hospitals and health system resilience in England: a qualitative assessment of frontline perspectives from the…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46794/psn-pdf
    May 17, 2018 - Implementation of diagnostic pauses in the ambulatory setting. May 17, 2018 Huang GC, Kriegel G, Wheaton C, et al. Implementation of diagnostic pauses in the ambulatory setting. BMJ Qual Saf. 2018;27(6):492-497. doi:10.1136/bmjqs-2017-007192. https://psnet.ahrq.gov/issue/implementation-diagnostic-pauses-ambulatory…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40853/psn-pdf
    October 19, 2011 - Adoption of National Quality Forum safe practices by magnet hospitals. October 19, 2011 Jayawardhana J, Welton JM, Lindrooth R. Adoption of National Quality Forum Safe Practices by Magnet® Hospitals. JONA: The Journal of Nursing Administration. 2011;41(9). doi:10.1097/nna.0b013e31822a71a7. https://psnet.ahrq.gov/i…
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