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psnet.ahrq.gov/node/38992/psn-pdf
April 16, 2018 - Safe patient outcomes occur with timely, standardized
communication of critical values.
April 16, 2018
https://psnet.ahrq.gov/issue/safe-patient-outcomes-occur-timely-standardized-communication-critical-
values
This article reports on failures surrounding critical test results and describes mechanisms to standardi…
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psnet.ahrq.gov/node/39255/psn-pdf
February 02, 2011 - The patient who falls: "It's always a trade-off."
February 2, 2011
Tinetti ME, Kumar C. The patient who falls: "It's always a trade-off". JAMA. 2010;303(3):258-66.
doi:10.1001/jama.2009.2024.
https://psnet.ahrq.gov/issue/patient-who-falls-its-always-trade
Through a case study, this article reviews evidence on risk…
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psnet.ahrq.gov/node/37654/psn-pdf
September 24, 2010 - The road to zero preventable birth injuries.
September 24, 2010
Mazza F, Kitchens J, Akin M, et al. The road to zero preventable birth injuries. Jt Comm J Qual Patient Saf.
2008;34(4):201-205.
https://psnet.ahrq.gov/issue/road-zero-preventable-birth-injuries
This article reports how a perinatal safety team, which …
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psnet.ahrq.gov/node/41636/psn-pdf
August 29, 2012 - Far more could be done to stop the deadly bacteria C. diff.
August 29, 2012
Eisler P. USA Today. August 16, 2012.
https://psnet.ahrq.gov/issue/far-more-could-be-done-stop-deadly-bacteria-c-diff
This newspaper article reports on how clinicians, hospitals, and health care systems can reduce incidence
of hospital-acq…
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psnet.ahrq.gov/node/41562/psn-pdf
August 01, 2012 - The Final Check: Say it Out Loud.
August 1, 2012
https://psnet.ahrq.gov/issue/final-check-say-it-out-loud
This Web site provides resources to help reduce incidence of mislabeled blood specimens based on just
culture concepts.
https://psnet.ahrq.gov/issue/final-check-say-it-out-loud
https://psnet.ahrq.gov/web-mm/ri…
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psnet.ahrq.gov/node/40553/psn-pdf
June 22, 2011 - Applying the Universal Protocol to improve patient safety
in radiology services.
June 22, 2011
PA-PSRS Patient Saf Advis. June 2011;8:63-69.
https://psnet.ahrq.gov/issue/applying-universal-protocol-improve-patient-safety-radiology-services
Exploring causes of wrong-site, wrong patient, and wrong procedure errors i…
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psnet.ahrq.gov/node/50584/psn-pdf
October 23, 2019 - Unprotected: broken promises in Georgia’s senior care
industry.
October 23, 2019
Schrade B, Teegardin C. Atlanta Journal-Constitution. Sept-October 2019.
https://psnet.ahrq.gov/issue/unprotected-broken-promises-georgias-senior-care-industry
Assisted living facilities have challenges that reduce the quality and saf…
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psnet.ahrq.gov/node/37743/psn-pdf
June 06, 2008 - Incidence and prevention of iatrogenic urethral injuries.
June 6, 2008
Kashefi C, Messer K, Barden R, et al. Incidence and prevention of iatrogenic urethral injuries. J Urol.
2008;179(6):2254-7; discussion 2257-8. doi:10.1016/j.juro.2008.01.108.
https://psnet.ahrq.gov/issue/incidence-and-prevention-iatrogenic-ureth…
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psnet.ahrq.gov/node/41447/psn-pdf
May 30, 2012 - Massachusetts hospitals launch patient apology program.
May 30, 2012
Gallegos A.
https://psnet.ahrq.gov/issue/massachusetts-hospitals-launch-patient-apology-program
This news article reports on a disclosure and apology program implemented in Massachusetts hospitals to
reduce liability lawsuits.
https://psnet.ahrq…
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psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
January 29, 2021 - Mixing fewer drugs together or using a local anesthetic alone for spinal injection reduces the chance
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psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd
May 01, 2016 - In Conversation With... Barbara Drew, RN, PhD
May 1, 2016
Also Read an Essay
Citation Text:
In Conversation With.. Barbara Drew, RN, PhD. PSNet [internet]. 2016.In Conversation With... Barbara Drew, RN, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare…
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psnet.ahrq.gov/training-catalog/niosh-training-nurses-shift-work-and-long-work-hours
October 13, 2025 - NIOSH Training for Nurses on Shift Work and Long Work Hours
Save
Save to your library
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Organization:
Organization
National Institute for Occupational Safety and Health (…
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psnet.ahrq.gov/node/39793/psn-pdf
August 25, 2010 - Infection Control in the Intensive Care Unit.
August 25, 2010
Crit Care Med. 2010;38:S265-S404.
https://psnet.ahrq.gov/issue/infection-control-intensive-care-unit
Articles in this special issue describe strategies to reduce infections in the intensive care unit, including
human factors design, guideline use…
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psnet.ahrq.gov/node/41831/psn-pdf
December 31, 2012 - The economics of health care quality and medical errors.
December 31, 2012
Andel C, Davidow SL, Hollander M, et al. The economics of health care quality and medical errors. J Health
Care Finance. 2012;39(1):39-50.
https://psnet.ahrq.gov/issue/economics-health-care-quality-and-medical-errors
Discussing the financia…
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psnet.ahrq.gov/node/36077/psn-pdf
July 05, 2006 - Perinatal patient safety from the perspective of nurse
executives: a round table discussion.
July 5, 2006
Thorman KE; Capitulo KL; Dubow J; Hanold K; Noonan M; Wehmeyer J.
https://psnet.ahrq.gov/issue/perinatal-patient-safety-perspective-nurse-executives-round-table-discussion
The authors summarize a discussion be…
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psnet.ahrq.gov/node/40406/psn-pdf
February 13, 2018 - Critical conversations: a call for a nonprocedural "time
out."
February 13, 2018
Sehgal NL, Fox M, Sharpe B, et al. Critical conversations: a call for a nonprocedural "time out". J Hosp
Med. 2011;6(4):225-30. doi:10.1002/jhm.853.
https://psnet.ahrq.gov/issue/critical-conversations-call-nonprocedural-time-out
This…
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psnet.ahrq.gov/node/34621/psn-pdf
September 27, 2017 - Human Factors and Medical Devices.
September 27, 2017
Center for Devices and Radiological Health, US Food and Drug Administration.
https://psnet.ahrq.gov/issue/human-factors-and-medical-devices
Human factors engineering (HFE) helps improve human performance and reduce the risks associated with
use error. The U.S. …
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psnet.ahrq.gov/node/41508/psn-pdf
July 11, 2012 - Complications in surgery: root cause analysis and
preventive measures.
July 11, 2012
Chung KC, Kotsis S. Complications in surgery: root cause analysis and preventive measures. Plast
Reconstr Surg. 2012;129(6):1421-1427. doi:10.1097/PRS.0b013e31824ecda0.
https://psnet.ahrq.gov/issue/complications-surgery-root-cause…
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psnet.ahrq.gov/node/36146/psn-pdf
February 05, 2019 - Guidelines for Design and Construction.
February 5, 2019
St Louis, Missouri; Facilities Guidelines Institute; 2018.
https://psnet.ahrq.gov/issue/guidelines-design-and-construction
These updated guidelines include design changes, such as the adoption of private rooms to reduce
medical error, interruptions, and hosp…
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psnet.ahrq.gov/node/38475/psn-pdf
March 10, 2011 - Effect of alerts for drug dosage adjustment in inpatients
with renal insufficiency.
March 10, 2011
Sellier E, Colombet I, Sabatier B, et al. Effect of alerts for drug dosage adjustment in inpatients with renal
insufficiency. J Am Med Inform Assoc. 2009;16(2):203-10. doi:10.1197/jamia.M2805.
https://psnet.ahrq.gov/…