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psnet.ahrq.gov/node/39558/psn-pdf
May 26, 2010 - ReCASTing the RCA: an improved model for performing
root cause analyses.
May 26, 2010
Pham JC, Kim GR, Natterman JP, et al. ReCASTing the RCA: An Improved Model for Performing Root
Cause Analyses. American Journal of Medical Quality. 2010;25(3). doi:10.1177/1062860609359533.
https://psnet.ahrq.gov/issue/recasting-…
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psnet.ahrq.gov/node/39576/psn-pdf
September 25, 2010 - Taking Care of Myself: A Guide for When I Leave the
Hospital.
September 25, 2010
Rockville, MD: Agency for Healthcare Research and Quality; April 2010. AHRQ Publication No. 10-0059.
https://psnet.ahrq.gov/issue/taking-care-myself-guide-when-i-leave-hospital
This guide provides patients with information they need t…
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psnet.ahrq.gov/node/38453/psn-pdf
January 02, 2017 - A multidisciplinary team approach to retained foreign
objects.
January 2, 2017
Cima RR, Kollengode A, Storsveen AS, et al. A multidisciplinary team approach to retained foreign objects.
Jt Comm J Qual Saf. 2009;35(3):123-132.
https://psnet.ahrq.gov/issue/multidisciplinary-team-approach-retained-foreign-objects
Th…
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psnet.ahrq.gov/node/846165/psn-pdf
March 15, 2023 - Do no unconscious harm.
March 15, 2023
Ortega RP. Do no unconscious harm. Science. 2023;379(6635):870-873. doi:10.1126/science.adh3698.
https://psnet.ahrq.gov/issue/do-no-unconscious-harm
Implicit biases can degrade decision making as they impact heuristics, test result interpretation, and
patient/physician commun…
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psnet.ahrq.gov/node/41083/psn-pdf
December 12, 2012 - Teams under pressure in the emergency department: an
interview study.
December 12, 2012
Flowerdew L, Brown R, Russ S, et al. Teams under pressure in the emergency department: an interview
study. Emerg Med J. 2012;29(12):e2. doi:10.1136/emermed-2011-200084.
https://psnet.ahrq.gov/issue/teams-under-pressure-emergenc…
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psnet.ahrq.gov/node/37638/psn-pdf
May 24, 2015 - Work hours regulations for house staff in psychiatry: bad
or good for residency training?
May 24, 2015
Rasminsky S, Lomonaco A, Auchincloss E. Work Hours Regulations for House Staff in Psychiatry: Bad or
Good for Residency Training? Academic Psychiatry. 2008;32(1). doi:10.1176/appi.ap.32.1.54.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/851660/psn-pdf
July 26, 2023 - From aviation to pediatric surgery.
July 26, 2023
Arredondo Montero J, Bardají Pascual C. From aviation to pediatric surgery. Clin Pediatr (Phila).
2024;63(4):557-559. doi:10.1177/00099228231176631.
https://psnet.ahrq.gov/issue/aviation-pediatric-surgery
Human factors strategies are increasingly applied in health …
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psnet.ahrq.gov/node/47475/psn-pdf
January 23, 2019 - Patient Safety and Quality Improvement.
January 23, 2019
Shah RK, ed. Otolaryngol Clin North Am. 2019;52:1-194.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-0
Articles in this special issue apply safety concepts to reducing preventable patient harm in otolaryngology.
The reviews highlight sy…
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psnet.ahrq.gov/node/44875/psn-pdf
March 02, 2016 - "Teach-back" from a patient's perspective.
March 2, 2016
Miller S, Lattanzio M, Cohen S. "Teach-back" from a patient's perspective. Nursing (Brux). 2016;46(2):63-4.
doi:10.1097/01.NURSE.0000476249.18503.f5.
https://psnet.ahrq.gov/issue/teach-back-patients-perspective
The teach-back method, having patients repeat i…
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psnet.ahrq.gov/node/42370/psn-pdf
June 19, 2013 - Resident Projects for Improvement.
June 19, 2013
Heilman J, ed. UNM CIR Journal of Quality Improvement in Healthcare. Albuquerque, NM: University of
New Mexico; May 2013.
https://psnet.ahrq.gov/issue/journal-quality-improvement-healthcare-second-edition
This publication outlines quality and safety improvement proj…
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psnet.ahrq.gov/node/43238/psn-pdf
June 04, 2014 - Administering just the diluent or one of two vaccine
components leaves patients unprotected.
June 4, 2014
ISMP Medication Safety Alert! Acute care edition. May 22, 2014;19:1-2.
https://psnet.ahrq.gov/issue/administering-just-diluent-or-one-two-vaccine-components-leaves-patients-
unprotected
Errors occur frequentl…
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psnet.ahrq.gov/node/40865/psn-pdf
September 12, 2016 - A review of current and emerging approaches to address
failure-to-rescue.
September 12, 2016
Taenzer AH, Pyke JB, McGrath SP. A review of current and emerging approaches to address failure-to-
rescue. Anesthesiology. 2011;115(2):421-31. doi:10.1097/ALN.0b013e318219d633.
https://psnet.ahrq.gov/issue/review-current-…
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psnet.ahrq.gov/node/46218/psn-pdf
October 29, 2017 - Nurses' knowledge and teaching of possible postpartum
complications.
October 29, 2017
Suplee PD, Bingham D, Kleppel L. Nurses' Knowledge and Teaching of Possible Postpartum
Complications. MCN Am J Matern Child Nurs. 2017;42(6):338-344. doi:10.1097/NMC.0000000000000371.
https://psnet.ahrq.gov/issue/nurses-knowledge…
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psnet.ahrq.gov/node/39257/psn-pdf
January 27, 2010 - Opportunities and Recommendations for State–Federal
Coordination to Improve Health System Performance: A
Focus on Patient Safety.
January 27, 2010
Buxbaum J. Portland, ME: National Academy for State Health Policy; January 2010.
https://psnet.ahrq.gov/issue/opportunities-and-recommendations-state-federal-coordinati…
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psnet.ahrq.gov/node/41321/psn-pdf
April 25, 2012 - Cognitive balanced model: a conceptual scheme of
diagnostic decision making.
April 25, 2012
Lucchiari C, Pravettoni G. Cognitive balanced model: a conceptual scheme of diagnostic decision making.
J Eval Clin Pract. 2012;18(1):82-8. doi:10.1111/j.1365-2753.2011.01771.x.
https://psnet.ahrq.gov/issue/cognitive-balanc…
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psnet.ahrq.gov/node/45638/psn-pdf
January 01, 2019 - Measures to improve diagnostic safety in clinical practice.
November 2, 2016
Singh H, Graber ML, Hofer TP. Measures to Improve Diagnostic Safety in Clinical Practice. J Patient Saf.
2019;15(4):311-316. doi:10.1097/PTS.0000000000000338.
https://psnet.ahrq.gov/issue/measures-improve-diagnostic-safety-clinical-practic…
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psnet.ahrq.gov/node/33952/psn-pdf
July 16, 2009 - Bar code label requirement for human drug products and
biological products.
July 16, 2009
Food and Drug Administration. Fed Register. February 26, 2004;69 9119-9171.
https://psnet.ahrq.gov/issue/bar-code-label-requirement-human-drug-products-and-biological-products
The US Food and Drug Administration (FDA) require…
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psnet.ahrq.gov/node/38292/psn-pdf
May 21, 2009 - The effect on medication errors of pharmacists charting
medication in an emergency department.
May 21, 2009
Vasileff HM, Whitten LE, Pink JA, et al. The effect on medication errors of pharmacists charting medication
in an emergency department. Pharm World Sci. 2009;31(3):373-9. doi:10.1007/s11096-008-9271-y.
https…
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psnet.ahrq.gov/node/867772/psn-pdf
September 01, 2013 - Universal ICU Decolonization: An Enhanced Protocl.
September 1, 2013
Agency for Healthcare Research and Quality. Universal ICU Decolonization: An Enhanced Protocol.
https://psnet.ahrq.gov/issue/universal-icu-decolonization-enhanced-protocl
Methicillin-resistant?Staphylococcus aureus (MRSA) is a known threat to pati…
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psnet.ahrq.gov/node/42197/psn-pdf
September 24, 2016 - Interruptions during nurses' work: a state-of-the-science
review.
September 24, 2016
Hopkinson SG, Jennings BM. Interruptions during nurses' work: A state-of-the-science review. Res Nurs
Health. 2013;36(1):38-53. doi:10.1002/nur.21515.
https://psnet.ahrq.gov/issue/interruptions-during-nurses-work-state-science-rev…