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psnet.ahrq.gov/node/45125/psn-pdf
January 26, 2023 - FDA and ISMP Lists of Look-Alike Drug Names With
Recommended Tall Man Letters.
January 26, 2023
Food and Drug Administration and Institute for Safe Medication Practices. Plymouth Meeting, PA; Institute
for Safe Medication Practices; January 2023.
https://psnet.ahrq.gov/issue/fda-and-ismp-lists-look-alike-drug-name…
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psnet.ahrq.gov/node/847543/psn-pdf
April 12, 2023 - What works in medication reconciliation: an on-treatment
and site analysis of the MARQUIS2 study.
April 12, 2023
Schnipper JL, Reyes Nieva H, Yoon CS, et al. What works in medication reconciliation: an on-treatment
and site analysis of the MARQUIS2 study. BMJ Qual Saf. 2023;32(8):457-469. doi:10.1136/bmjqs-2022-
0…
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psnet.ahrq.gov/node/857445/psn-pdf
January 01, 2024 - The racial disparities in maternal mortality and impact of
structural racism and implicit racial bias on pregnant
Black women: a review of the literature.
December 6, 2023
Montalmant KE, Ettinger AK. The racial disparities in maternal mortality and impact of structural racism and
implicit racial bias on pregnant b…
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psnet.ahrq.gov/node/865928/psn-pdf
May 22, 2024 - Teamwork climate, safety climate, and physician burnout:
a national, cross-sectional study.
May 22, 2024
Rotenstein L, Wang H, West CP, et al. Teamwork climate, safety climate, and physician burnout: a
national, cross-sectional study. Jt Comm J Qual Patient Saf. 2024;50(6):458-462.
doi:10.1016/j.jcjq.2024.03.007.
…
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psnet.ahrq.gov/node/47883/psn-pdf
May 29, 2019 - Patient Safety in Obstetrics and Gynecology.
May 29, 2019
Gluck PA, ed. Obstet Gynecol Clin North Am. 2019;46:H1-H8, 199-398.
https://psnet.ahrq.gov/issue/patient-safety-obstetrics-and-gynecology
Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. Articles in
this speci…
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psnet.ahrq.gov/node/862131/psn-pdf
February 07, 2024 - Prospective study of the multisite spread of a medication
safety intervention: factors common to hospitals with
improved outcomes.
February 7, 2024
Kaplan HC, Goldstein SL, Rubinson C, et al. Prospective study of the multisite spread of a medication
safety intervention: factors common to hospitals with improved ou…
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psnet.ahrq.gov/node/47026/psn-pdf
January 23, 2019 - Charter on Physician Well-being.
January 23, 2019
Thomas LR, Ripp JA, West CP. Charter on Physician Well-being. JAMA. 2018;319(15):1541-1542.
doi:10.1001/jama.2018.1331.
https://psnet.ahrq.gov/issue/charter-physician-well-being
Clinician burnout is a growing concern with known patient safety implications. This com…
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psnet.ahrq.gov/node/837044/psn-pdf
May 04, 2022 - How Discrimination in Health Care Affects Older
Americans, and What Health Systems and Providers Can
Do.
May 4, 2022
Doty MM, Horstman C, Shah A et al. Issue Brief. New York, NY: Commonwealth Fund: April 2022.
https://psnet.ahrq.gov/issue/how-discrimination-health-care-affects-older-americans-and-what-health-
sys…
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psnet.ahrq.gov/node/837039/psn-pdf
May 04, 2022 - The Joint Commission's new and revised workplace
violence prevention standards for hospitals: a major step
forward toward improved quality and safety.
May 4, 2022
Arnetz JE. The Joint Commission's new and revised workplace violence prevention standards for hospitals:
a major step forward toward improved quality an…
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psnet.ahrq.gov/node/60725/psn-pdf
July 29, 2020 - The tradeoffs between safety and alert fatigue: data from
a national evaluation of hospital medication-related
clinical decision support.
July 29, 2020
Co Z, Holmgren AJ, Classen DC, et al. The tradeoffs between safety and alert fatigue: data from a national
evaluation of hospital medication-related clinical decis…
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psnet.ahrq.gov/node/61125/psn-pdf
November 11, 2020 - The Anesthesia Patient Safety Foundation Stoelting
Conference 2019: perioperative deterioration--early
recognition, rapid intervention, and the end of failure-to-
rescue.
November 11, 2020
Lin D, Peden CJ, Langness SM, et al. The Anesthesia Patient Safety Foundation Stoelting Conference
2019: perioperative deteri…
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psnet.ahrq.gov/node/46606/psn-pdf
July 10, 2019 - Implementation of a mock root cause analysis to provide
simulated patient safety training.
July 10, 2019
Murphy M, Duff J, Whitney J, et al. Implementation of a mock root cause analysis to provide simulated
patient safety training. BMJ Open Qual. 2017;6(2). doi:10.1136/bmjoq-2017-000096.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/47680/psn-pdf
January 16, 2019 - Perioperative medication errors: uncovering risk from
behind the drapes.
January 16, 2019
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. 2018;15(4):1-17.
https://psnet.ahrq.gov/issue/perioperative-medication-errors-uncovering-risk-behind-drapes
The operating room environment harbors particular pat…
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psnet.ahrq.gov/node/34642/psn-pdf
June 24, 2015 - Human factor in cardiac surgery: errors and near misses
in a high technology medical domain.
June 24, 2015
Carthey J, de Leval MR, Reason JT. The human factor in cardiac surgery: errors and near misses in a high
technology medical domain. Ann Thorac Surg. 2001;72(1):300-5.
https://psnet.ahrq.gov/issue/human-factor…
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psnet.ahrq.gov/node/836749/psn-pdf
March 16, 2022 - Comparison of a focused family cancer history
questionnaire to family history documentation in the
electronic medical record.
March 16, 2022
Clift K, Macklin-Mantia S, Barnhorst M, et al. Comparison of a focused family cancer history questionnaire
to family history documentation in the electronic medical record. J…
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psnet.ahrq.gov/node/72790/psn-pdf
March 03, 2021 - Parent engagement in perinatal mortality reviews: an
online survey of clinicians from six high-income
countries.
March 3, 2021
Boyle FM, Horey D, Siassakos D, et al. Parent engagement in perinatal mortality reviews: an online survey
of clinicians from six high?income countries. BJOG. 2020;128(4):696-703. doi:10.11…
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psnet.ahrq.gov/node/34707/psn-pdf
September 29, 2017 - National Patient Safety Foundation agenda for research
and development in patient safety.
September 29, 2017
Cooper JB, Gaba DM, Liang B, et al. The National Patient Safety Foundation agenda for research and
development in patient safety. MedGenMed. 2000;2(3):E38.
https://psnet.ahrq.gov/issue/national-patient-safe…
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psnet.ahrq.gov/node/46618/psn-pdf
June 25, 2018 - Identifying quality markers of a safe surgical ward: an
interview study of patients, clinical staff, and
administrators.
June 25, 2018
Hassen Y, Singh P, Pucher PH, et al. Identifying quality markers of a safe surgical ward: An interview study
of patients, clinical staff, and administrators. Surgery. 2018;163(6):1…
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psnet.ahrq.gov/node/37878/psn-pdf
February 03, 2011 - Electromagnetic interference from radio frequency
identification inducing potentially hazardous incidents in
critical care medical equipment.
February 3, 2011
van der Togt R, van Lieshout EJ, Hensbroek R, et al. Electromagnetic interference from radio frequency
identification inducing potentially hazardous incide…
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psnet.ahrq.gov/node/46862/psn-pdf
February 21, 2018 - Considering human factors and developing systems-
thinking behaviours to ensure patient safety.
February 21, 2018
Vosper H; Lim R; Knight C; et al; CIEHF Pharmaceutical Human Factors Special Interest Group. Clinical
Pharmacist. 2018;10(2).
https://psnet.ahrq.gov/issue/considering-human-factors-and-developing-syste…