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psnet.ahrq.gov/node/73489/psn-pdf
July 15, 2021 - A diagnostic time-out to improve differential diagnosis in
pediatric abdominal pain.
July 15, 2021
Kasick RT, Melvin JE, Perera ST, et al. A diagnostic time-out to improve differential diagnosis in pediatric
abdominal pain. Diagnosis (Berl). 2021;8(2):209-217. doi:10.1515/dx-2019-0054.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/73249/psn-pdf
May 12, 2021 - I-PASS handover system: a decade of evidence demands
action.
May 12, 2021
Shahian DM. I-PASS handover system: a decade of evidence demands action. BMJ Qual Saf.
2021;30(10):769-774. doi:10.1136/bmjqs-2021-013314.
https://psnet.ahrq.gov/issue/i-pass-handover-system-decade-evidence-demands-action
The I-PASS structu…
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psnet.ahrq.gov/node/72674/psn-pdf
January 27, 2021 - The effect of blue-enriched lighting on medical error rate
in a university hospital ICU.
January 27, 2021
Chen Y, Broman AT, Priest G, et al. The Effect of Blue-Enriched Lighting on Medical Error Rate in a
University Hospital ICU. Jt Comm J Qual Saf. 2021;47(3):165-175. doi:10.1016/j.jcjq.2020.11.007.
https://psne…
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psnet.ahrq.gov/node/46681/psn-pdf
April 16, 2018 - Trainee autonomy and patient safety.
April 16, 2018
George BC, Dunnington GL, DaRosa DA. Trainee autonomy and patient safety. Ann Surg.
2018;267(5):820-822. doi:10.1097/SLA.0000000000002599.
https://psnet.ahrq.gov/issue/trainee-autonomy-and-patient-safety
Reduced resident work hours and insufficient senior surgeon…
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psnet.ahrq.gov/node/72761/psn-pdf
February 17, 2021 - Using ventilator splitters during the COVID-19 pandemic--
letter to health care providers.
February 17, 2021
Silver Spring, MD: Division of Industry and Consumer Education, US Food and Drug Administration;
February 9. 2021.
https://psnet.ahrq.gov/issue/using-ventilator-splitters-during-covid-19-pandemic-letter-hea…
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psnet.ahrq.gov/node/47028/psn-pdf
May 02, 2018 - Medication errors 2018: the year in review.
May 2, 2018
Valentine D, Ingram V, Fobi BNN, Brahmbhatt V. Pharmacy Practice News. April 4, 2018.
https://psnet.ahrq.gov/issue/medication-errors-2018-year-review
Despite considerable effort, medication errors continue to occur and result in patient harm. Summari…
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psnet.ahrq.gov/node/764411/psn-pdf
March 02, 2022 - Nowhere is safe: record number of patients contracted
Covid in the hospital in January.
March 2, 2022
Levy R, Vestal AJ. Politico. February 19, 2022.
https://psnet.ahrq.gov/issue/nowhere-safe-record-number-patients-contracted-covid-hospital-january
Transmission of COVID-19 in the health care setting continues to b…
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psnet.ahrq.gov/node/50425/psn-pdf
September 04, 2019 - Why doctors still offer treatments that may not help.
September 4, 2019
Frakt A. New York Times. August 26, 2019.
https://psnet.ahrq.gov/issue/why-doctors-still-offer-treatments-may-not-help
The slow adoption of improvement innovations is a persistent challenge to high-quality and safe patient
care. This newspaper…
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psnet.ahrq.gov/node/45658/psn-pdf
November 09, 2016 - Hospitals installed more sinks to stop infections. The
sinks can make the problem worse.
November 9, 2016
Branswell H. STAT. October 25, 2016.
https://psnet.ahrq.gov/issue/hospitals-installed-more-sinks-stop-infections-sinks-can-make-problem-worse
Hospitals have sought to improve hand hygiene with interventions su…
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psnet.ahrq.gov/node/60750/psn-pdf
August 06, 2020 - Missed breast cancer: effects of subconscious bias and
lesion characteristics.
August 6, 2020
Lamb LR, Mohallem Fonseca M, Verma R, et al. Missed breast cancer: effects of subconscious bias and
lesion characteristics. RadioGraphics. 2020;40(4):941-960. doi:10.1148/rg.2020190090.
https://psnet.ahrq.gov/issue/missed…
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psnet.ahrq.gov/node/854252/psn-pdf
October 04, 2023 - Standardization and visualization of the surgical time-out.
October 4, 2023
Levy BE, Wilt WS, Lantz S, et al. Standardization and visualization of the surgical time-out. J Patient Saf.
2023;19(7):453-459. doi:10.1097/pts.0000000000001156.
https://psnet.ahrq.gov/issue/standardization-and-visualization-surgical-time-…
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psnet.ahrq.gov/node/46336/psn-pdf
August 23, 2017 - Improving the Working Environment for Safe Surgical
Care.
August 23, 2017
Short-Life Working Group on Hospital Reports. Edinburgh, Scotland: Royal College of Surgeons of
Edinburgh; July 31, 2017.
https://psnet.ahrq.gov/issue/improving-working-environment-safe-surgical-care
Surgical training is demanding and can r…
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psnet.ahrq.gov/node/44333/psn-pdf
July 15, 2015 - One hospital's initiatives to encourage safe opioid use.
July 15, 2015
Surprise JK, Simpson MH. One Hospital's Initiatives to Encourage Safe Opioid Use. J Infus Nurs.
2015;38(4):278-83. doi:10.1097/NAN.0000000000000110.
https://psnet.ahrq.gov/issue/one-hospitals-initiatives-encourage-safe-opioid-use
This commentar…
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psnet.ahrq.gov/node/60800/psn-pdf
January 01, 2021 - Changing hospital organisational culture for improved
patient outcomes: developing and implementing the
Leadership Saves Lives intervention.
August 12, 2020
Linnander EL, McNatt Z, Boehmer K, et al. Changing hospital organisational culture for improved patient
outcomes: developing and implementing the leadership s…
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psnet.ahrq.gov/node/46384/psn-pdf
November 14, 2018 - Peggy Lillis Foundation.
November 14, 2018
266 12th Street #6, Brooklyn, NY 11215.
https://psnet.ahrq.gov/issue/peggy-lillis-foundation
Clostridium difficile infections are considered a serious hospital-acquired infection. This grassroots
foundation employs educational, policy, and advocacy strategies aimed at red…
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psnet.ahrq.gov/node/837605/psn-pdf
June 29, 2022 - Under the Skin. The Hidden Toll of Racism on American
Lives and on the Health of our Nation.
June 29, 2022
Villarosa L. New York, NT: Doubleday: 2022. ISBN 9780385544887.
https://psnet.ahrq.gov/issue/under-skin-hidden-toll-racism-american-lives-and-health-our-nation
Health inequities are receiving increased …
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psnet.ahrq.gov/node/74064/psn-pdf
May 27, 2021 - Achieving zero inequity: lessons learned from patient
safety.
May 27, 2021
Gandhi TK. NEJM Catalyst. May 27, 2021.
https://psnet.ahrq.gov/issue/achieving-zero-inequity-lessons-learned-patient-safety
The COVID-19 pandemic has shown a spotlight on bias, disparities, and inequity in the healthcare system.
The author…
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psnet.ahrq.gov/node/46253/psn-pdf
August 28, 2017 - Diagnostic stewardship—leveraging the laboratory to
improve antimicrobial use.
August 28, 2017
Morgan DJ, Malani P, Diekema DJ. Diagnostic Stewardship-Leveraging the Laboratory to Improve
Antimicrobial Use. JAMA. 2017;318(7):607-608. doi:10.1001/jama.2017.8531.
https://psnet.ahrq.gov/issue/diagnostic-stewardship-l…
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psnet.ahrq.gov/node/41425/psn-pdf
June 19, 2012 - Mortality and morbidity meetings: an untapped resource
for improving the governance of patient safety?
June 19, 2012
Higginson J, Walters R, Fulop NJ. Mortality and morbidity meetings: an untapped resource for improving
the governance of patient safety? BMJ Qual Saf. 2012;21(7):576-585. doi:10.1136/bmjqs-2011-00060…
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psnet.ahrq.gov/node/867016/psn-pdf
October 23, 2024 - An automated, dynamic radiation oncology prescription
checking system.
October 23, 2024
Pashtan IM, Kosak T, Shin K-Y, et al. An automated, dynamic radiation oncology prescription checking
system. Pract Radiat Oncol. 2024;14(4):343-352. doi:10.1016/j.prro.2023.12.002.
https://psnet.ahrq.gov/issue/automated-dynamic…