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psnet.ahrq.gov/node/46945/psn-pdf
August 29, 2018 - Patient safety initiatives in obstetrics: a rapid review.
August 29, 2018
Antony J, Zarin W, Pham B', et al. Patient safety initiatives in obstetrics: a rapid review. BMJ Open.
2018;8(7):e020170. doi:10.1136/bmjopen-2017-020170.
https://psnet.ahrq.gov/issue/patient-safety-initiatives-obstetrics-rapid-review
Variou…
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psnet.ahrq.gov/node/43772/psn-pdf
June 24, 2019 - Betsy Lehman Center for Patient Safety.
June 24, 2019
501 Boylston Street, 5th Floor, Boston, MA, 02116 info@BetsyLehmanCenterMA.gov
https://psnet.ahrq.gov/issue/betsy-lehman-center-patient-safety
The Betsy Lehman Center is a nonregulatory Massachusetts state agency named for Betsy Lehman, the
Boston Globe columni…
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psnet.ahrq.gov/node/47089/psn-pdf
May 09, 2018 - Leadership Survey: Immunization Against Burnout:
Insights Report.
May 9, 2018
Swensen S, Strongwater S, Mohta NS. NEJM Catalyst: Insights Report. April 12, 2018.
https://psnet.ahrq.gov/issue/leadership-survey-immunization-against-burnout-insights-report
Clinician burnout presents challenges to organizational and p…
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psnet.ahrq.gov/node/39263/psn-pdf
February 03, 2010 - Is there a benefit to multidisciplinary rounds in an open
trauma intensive care unit regarding ventilator-associated
pneumonia?
February 3, 2010
Johnson V, Mangram A, Mitchell C, et al. Is there a benefit to multidisciplinary rounds in an open trauma
intensive care unit regarding ventilator-associated pneumonia? A…
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psnet.ahrq.gov/node/60975/psn-pdf
September 30, 2020 - Evidence on Use of Clinical Reasoning Checklists for
Diagnostic Error Reduction.
September 30, 2020
Zwaan L, Staal J. Rockville, MD: Agency for Healthcare Research and Quality; September 2020.
AHRQ Publication No. 20-0040-3-EF.
https://psnet.ahrq.gov/issue/evidence-use-clinical-reasoning-checklists-diagnostic…
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psnet.ahrq.gov/node/74703/psn-pdf
January 26, 2022 - Research to improve diagnosis: time to study the real
world.
January 26, 2022
Ranji SR, Thomas EJ. Research to improve diagnosis: time to study the real world. BMJ Qual Saf.
2022;31(4):255-258. doi:10.1136/bmjqs-2021-014071.
https://psnet.ahrq.gov/issue/research-improve-diagnosis-time-study-real-world
Diagnostic …
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psnet.ahrq.gov/node/43701/psn-pdf
July 03, 2016 - Blink or think: can further reflection improve initial
diagnostic impressions?
July 3, 2016
Hess BJ, Lipner RS, Thompson V, et al. Blink or think: can further reflection improve initial diagnostic
impressions? Acad Med. 2015;90(1):112-118. doi:10.1097/ACM.0000000000000550.
https://psnet.ahrq.gov/issue/blink-or-thi…
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psnet.ahrq.gov/node/60851/psn-pdf
August 26, 2020 - Situativity: A Family of Social Cognitive Theories for
Clinical Reasoning and Error.
August 26, 2020
Durning S, Holmboe E, Graber ML, eds. Diagnosis(Berl). 2020;7(3):151-344.
https://psnet.ahrq.gov/issue/situativity-family-social-cognitive-theories-clinical-reasoning-and-error
Challenges to effective clinical reas…
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psnet.ahrq.gov/node/48068/psn-pdf
June 12, 2019 - Health Professions Education.
June 12, 2019
Dhaliwal G, Olson APJ, Singhal G, eds. Diagnosis (Berl). 2019;6(2):75-185.
https://psnet.ahrq.gov/issue/health-professions-education
Clinical and educational environments are increasingly focusing on improving diagnosis. This special issue
explores an overarching approac…
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psnet.ahrq.gov/node/47632/psn-pdf
April 10, 2019 - Perception of the usability and implementation of a
metacognitive mnemonic to check cognitive errors in
clinical setting.
April 10, 2019
Chew KS, van Merrienboer JJG, Durning SJ. Perception of the usability and implementation of a
metacognitive mnemonic to check cognitive errors in clinical setting. BMC Med Educ. …
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psnet.ahrq.gov/node/837905/psn-pdf
August 24, 2022 - How cisgender clinicians can help prevent harm during
encounters with transgender patients.
August 24, 2022
doi:10.1001/amajethics.2022.753.
https://psnet.ahrq.gov/issue/how-cisgender-clinicians-can-help-prevent-harm-during-encounters-
transgender-patients
Implicit bias, discrimination, and stigmatization impact …
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psnet.ahrq.gov/node/61003/psn-pdf
October 07, 2020 - Making Complaints Count: Supporting Complaints
Handling in the NHS and UK Government Departments.
October 7, 2020
Manchester, UK: The Parliamentary and Health Service Ombudsman; July 15, 2020. ISBN
9781528620666.
https://psnet.ahrq.gov/issue/making-complaints-count-supporting-complaints-handling-nhs-and-uk-
gover…
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psnet.ahrq.gov/node/73668/psn-pdf
September 01, 2021 - Leadership: an effective human factor during COVID-19.
September 1, 2021
Dhahri AA, Refson J. Leadership: an effective human factor during COVID-19. BMJ Leader. 2021;5:203-
205. doi:10.1136/leader-2020-000384.
https://psnet.ahrq.gov/issue/leadership-effective-human-factor-during-covid-19
Hierarchy and professional…
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psnet.ahrq.gov/node/837024/psn-pdf
May 04, 2022 - The potential for leveraging machine learning to filter
medication alerts.
May 4, 2022
Liu S, Kawamoto K, Del Fiol G, et al. The potential for leveraging machine learning to filter medication
alerts. J Am Med Inform Assoc. 2022;29(5):891-899. doi:10.1093/jamia/ocab292.
https://psnet.ahrq.gov/issue/potential-levera…
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psnet.ahrq.gov/node/43677/psn-pdf
November 19, 2014 - Reporting and Learning Systems for Medication Errors:
The Role of Pharmacovigilance Centres.
November 19, 2014
Bencheikh SR, Cousins D, Benabdallah G, et al. Geneva, Switzerland: World Health Organization; October
2014. ISBN: 9789241507943.
https://psnet.ahrq.gov/issue/reporting-and-learning-systems-medication-err…
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psnet.ahrq.gov/node/43758/psn-pdf
March 17, 2015 - A patient safety checklist for the cardiac catheterisation
laboratory.
March 17, 2015
Cahill TJ, Clarke SC, Simpson IA, et al. A patient safety checklist for the cardiac catheterisation laboratory.
Heart. 2015;101(2):91-3. doi:10.1136/heartjnl-2014-306927.
https://psnet.ahrq.gov/issue/patient-safety-checklist-card…
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psnet.ahrq.gov/node/34100/psn-pdf
February 09, 2011 - Safety of patients isolated for infection control.
February 9, 2011
Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infection control. JAMA.
2003;290(14):1899-1905.
https://psnet.ahrq.gov/issue/safety-patients-isolated-infection-control
This study discovered that patients isolated for coloniza…
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psnet.ahrq.gov/node/73396/psn-pdf
June 16, 2021 - The impact of the built environment on patient falls in
hospital rooms: an integrative review.
June 16, 2021
Pati D, Valipoor S, Lorusso L, et al. The impact of the built environment on patient falls in hospital rooms:
an integrative review. J Patient Saf. 2021;17(4):273-281. doi:10.1097/pts.0000000000000613.
http…
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psnet.ahrq.gov/node/60801/psn-pdf
August 12, 2020 - Targeting zero harm: a stretch goal that risks breaking the
spring.
August 12, 2020
Meddings J, Saint S, Lilford RJ, et al. Targeting zero harm: a stretch goal that risks breaking the spring.
NEJM Catal Innov Care Deliv. 2020;1(4). doi:10.1056/cat.20.0354.
https://psnet.ahrq.gov/issue/targeting-zero-harm-stretch-g…
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psnet.ahrq.gov/node/42643/psn-pdf
October 09, 2013 - FDA requiring color changes to Duragesic (fentanyl) pain
patches to aid safety?emphasizing that accidental
exposure to used patches can cause death.
October 9, 2013
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 23, 2013.
https://psnet.ahrq.gov/issue/fda-requiring-color-change…