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psnet.ahrq.gov/node/38290/psn-pdf
February 17, 2011 - Revisiting duty-hour limits — IOM recommendations for
patient safety and resident education.
February 17, 2011
Iglehart JK. Revisiting duty-hour limits--IOM recommendations for patient safety and resident education. N
Engl J Med. 2008;359(25):2633-5. doi:10.1056/NEJMp0808736.
https://psnet.ahrq.gov/issue/revisitin…
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psnet.ahrq.gov/node/61096/psn-pdf
November 04, 2020 - Wrong drug and wrong dose dispensing errors identified
in pharmacist professional liability claims.
November 4, 2020
Reiner G, Pierce SL, Flynn J. J Am Pharm Assoc (2003). 2020;60(5):e50-e56.
https://psnet.ahrq.gov/issue/wrong-drug-and-wrong-dose-dispensing-errors-identified-pharmacist-
professional-liability
Des…
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psnet.ahrq.gov/node/44148/psn-pdf
November 06, 2015 - Role of cognition in generating and mitigating clinical
errors.
November 6, 2015
Patel VL, Kannampallil TG, Shortliffe EH. Role of cognition in generating and mitigating clinical errors. BMJ
Qual Saf. 2015;24(7):468-474. doi:10.1136/bmjqs-2014-003482.
https://psnet.ahrq.gov/issue/role-cognition-generating-and-miti…
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psnet.ahrq.gov/node/34649/psn-pdf
June 11, 2014 - On error management: lessons from aviation.
June 11, 2014
Helmreich RL. On error management: lessons from aviation. BMJ . 2000;320(7237):781-785.
https://psnet.ahrq.gov/issue/error-management-lessons-aviation
In this perspective, the author draws on analogies from aviation to frame the issues of patient safety and
…
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psnet.ahrq.gov/node/60846/psn-pdf
January 01, 2021 - Safety climate associated with adverse events in nursing
homes: a national VA study.
August 26, 2020
Quach ED, Kazis LE, Zhao S, et al. Safety climate associated with adverse events in nursing homes: a
national VA study. J Am Med Dir Assoc. 2021;22(2):388-392. doi:10.1016/j.jamda.2020.05.028.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/866115/psn-pdf
June 12, 2024 - Defining, identifying and addressing problematic
polypharmacy within multimorbidity in primary care: a
scoping review.
June 12, 2024
Tsang JY, Sperrin M, Blakeman T, et al. Defining, identifying and addressing problematic polypharmacy
within multimorbidity in primary care: a scoping review. BMJ Open. 2024;14(5):e0…
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psnet.ahrq.gov/node/38224/psn-pdf
February 18, 2011 - Hospital readmissions: physician awareness and
communication practices.
February 18, 2011
Roy CL, Kachalia A, Woolf S, et al. Hospital readmissions: physician awareness and communication
practices. J Gen Intern Med. 2009;24(3):374-80. doi:10.1007/s11606-008-0848-x.
https://psnet.ahrq.gov/issue/hospital-readmission…
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psnet.ahrq.gov/node/865967/psn-pdf
May 29, 2024 - Impact of diagnostic management team on patient time to
diagnosis and percent of accurate and clinically
actionable diagnoses.
May 29, 2024
Brashear J, Mize R, Laposata M, et al. Impact of diagnostic management team on patient time to diagnosis
and percent of accurate and clinically actionable diagnoses. Diagnosis…
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psnet.ahrq.gov/node/45895/psn-pdf
February 22, 2017 - Opioids for pain management in older adults: strategies
for safe prescribing.
February 22, 2017
Davies PS. Opioids for pain management in older adults. Nurse Pract. 2017;42(2).
doi:10.1097/01.npr.0000511772.62176.10.
https://psnet.ahrq.gov/issue/opioids-pain-management-older-adults-strategies-safe-prescribing
Use…
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psnet.ahrq.gov/node/47109/psn-pdf
June 06, 2018 - Principles of automation for patient safety in intensive
care: learning from aviation.
June 6, 2018
Dominiczak J, Khansa L. Principles of Automation for Patient Safety in Intensive Care: Learning From
Aviation. Jt Comm J Qual Patient Saf. 2018;44(6):366-371. doi:10.1016/j.jcjq.2017.11.008.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/862152/psn-pdf
February 07, 2024 - Risk identification and prediction of complaints and
misconduct against health practitioners: a scoping
review.
February 7, 2024
Wang Y, Ram SS, Scahill S. Risk identification and prediction of complaints and misconduct against health
practitioners: a scoping review. Int J Qual Health Care. 2024;36(1):mzad114. doi…
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psnet.ahrq.gov/node/45763/psn-pdf
December 19, 2017 - Expanded pharmacy technician roles: accepting verbal
prescriptions and communicating prescription transfers.
December 19, 2017
Frost TP, Adams AJ. Expanded pharmacy technician roles: Accepting verbal prescriptions and
communicating prescription transfers. Res Social Adm Pharm. 2017;13(6):1191-1195.
doi:10.1016/j.s…
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psnet.ahrq.gov/node/35726/psn-pdf
February 09, 2011 - Sleep deprivation and clinical performance.
February 9, 2011
Weinger MB, Ancoli-Israel S. Sleep deprivation and clinical performance. JAMA. 2002;287(8):955-7.
https://psnet.ahrq.gov/issue/sleep-deprivation-and-clinical-performance
This review discusses evidence for the role sleep deprivation plays on performance in…
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psnet.ahrq.gov/node/73257/psn-pdf
December 01, 2021 - Peer Review of a Report on Strategies to Improve Patient
Safety.
May 12, 2021
Washington DC: National Academies of Sciences, Engineering, and Medicine; 2021. ISBN:
9780309462808.
https://psnet.ahrq.gov/issue/peer-review-report-strategies-improve-patient-safety
The Patient Safety and Quality Improvement Act of 200…
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psnet.ahrq.gov/node/46190/psn-pdf
August 17, 2017 - Preventing harm in the ICU—building a culture of safety
and engaging patients and families.
August 17, 2017
Thornton KC, Schwarz JJ, Gross K, et al. Preventing Harm in the ICU-Building a Culture of Safety and
Engaging Patients and Families. Crit Care Med. 2017;45(9):1531-1537.
doi:10.1097/CCM.0000000000002556.
ht…
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psnet.ahrq.gov/node/73280/psn-pdf
May 19, 2021 - Rates of serious surgical errors in California and plans to
prevent recurrence.
May 19, 2021
Cohen AJ, Lui H, Zheng M, et al. Rates of serious surgical errors in California and plans to prevent
recurrence. JAMA Netw Open. 2021;4(5):e217058. doi:10.1001/jamanetworkopen.2021.7058.
https://psnet.ahrq.gov/issue/rates-…
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psnet.ahrq.gov/node/46375/psn-pdf
November 29, 2017 - Fall risk and prevention agreement: engaging patients
and families with a partnership for patient safety.
November 29, 2017
Vonnes C, Wolf D. Fall risk and prevention agreement: engaging patients and families with a partnership
for patient safety. BMJ Open Qual. 2017;6(2):e000038. doi:10.1136/bmjoq-2017-000038.
ht…
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psnet.ahrq.gov/node/836996/psn-pdf
April 27, 2022 - Does a suggested diagnosis in a general practitioners'
referral question impact diagnostic reasoning: an
experimental study.
April 27, 2022
Staal J, Speelman M, Brand R, et al. Does a suggested diagnosis in a general practitioners’ referral
question impact diagnostic reasoning: an experimental study. BMC Med Educ.…
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psnet.ahrq.gov/node/46654/psn-pdf
December 13, 2017 - Organisational paradoxes in speaking up for safety:
implications for the interprofessional field.
December 13, 2017
Rowland P. Organisational paradoxes in speaking up for safety: Implications for the interprofessional field.
J Interprof Care. 2017;31(5):553-556. doi:10.1080/13561820.2017.1321305.
https://psnet.ahr…
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psnet.ahrq.gov/node/865919/psn-pdf
May 22, 2024 - Potentially avoidable hospitalizations among historically
marginalized nursing home residents.
May 22, 2024
Estrada LV, Barcelona V, Dhingra L, et al. Potentially avoidable hospitalizations among historically
marginalized nursing home residents. JAMA Netw Open. 2024;7(5):e249312.
doi:10.1001/jamanetworkopen.2024.9…