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psnet.ahrq.gov/node/39597/psn-pdf
July 14, 2010 - Ten strategies to improve management of abnormal test
result alerts in the electronic health record.
July 14, 2010
Singh H, Wilson L, Reis B, et al. Ten strategies to improve management of abnormal test result alerts in the
electronic health record. J Patient Saf. 2010;6(2):121-123. doi:10.1097/PTS.0b013e3181ddf652…
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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/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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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-n.docx
June 02, 2025 - AHRQ Safety Program for Reducing CAUTI in Hospitals
Appendix N. Skin Care in the Incontinent Patient
An indwelling urinary catheter is not the answer for urinary incontinence.
· Good skin care technique will prevent skin breakdown.
· Use perineal cleansing products as needed.
· Avoid use of agents containing alcoho…
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psnet.ahrq.gov/node/41721/psn-pdf
October 03, 2012 - Rural inpatient telepharmacy consultation demonstration
for after-hours medication review.
October 3, 2012
Cole SL, Grubbs JH, Din C, et al. Rural inpatient telepharmacy consultation demonstration for after-hours
medication review. Telemed J E Health. 2012;18(7):530-7. doi:10.1089/tmj.2011.0222.
https://psnet.ahrq…
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psnet.ahrq.gov/node/44299/psn-pdf
November 06, 2015 - Nurse practitioner–led medication reconciliation in critical
access hospitals.
November 6, 2015
Young L, Barnason S, Hays K, et al. Nurse Practitioner–led Medication Reconciliation in Critical Access
Hospitals. The Journal for Nurse Practitioners. 2015;11(5). doi:10.1016/j.nurpra.2015.03.005.
https://psnet.ahrq.go…
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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/864383/psn-pdf
March 13, 2024 - Cyberattack on UnitedHealth still impacting prescription
access: "These are threats to life".
March 13, 2024
Sganga N, Triay A. CBS Evening News. February 29, 2024.
https://psnet.ahrq.gov/issue/cyberattack-unitedhealth-still-impacting-prescription-access-these-are-threats-
life
As health care becomes more technol…
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psnet.ahrq.gov/node/43952/psn-pdf
March 04, 2015 - Improving resident morning sign-out by use of daily
events reports.
March 4, 2015
Nabors C, Patel D, Khera S, et al. Improving resident morning sign-out by use of daily events reports. J
Patient Saf. 2015;11(1):36-41. doi:10.1097/PTS.0b013e31829e4f56.
https://psnet.ahrq.gov/issue/improving-resident-morning-sign-ou…
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psnet.ahrq.gov/node/38945/psn-pdf
November 25, 2009 - The negative impact of nurse-physician disruptive
behavior on patient safety: a review of the literature.
November 25, 2009
Saxton R, Hines T, Enriquez M. The negative impact of nurse-physician disruptive behavior on patient
safety: a review of the literature. J Patient Saf. 2009;5(3):180-183. doi:10.1097/pts.0b013…
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psnet.ahrq.gov/node/43819/psn-pdf
July 16, 2015 - Intercepting wrong-patient orders in a computerized
provider order entry system.
July 16, 2015
Green RA, Hripcsak G, Salmasian H, et al. Intercepting wrong-patient orders in a computerized provider
order entry system. Ann Emerg Med. 2015;65(6):679-686.e1. doi:10.1016/j.annemergmed.2014.11.017.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/40985/psn-pdf
December 07, 2011 - Implementing the World Health Organization surgical
safety checklist: a model for future perioperative
initiatives.
December 7, 2011
Styer KA, Ashley SW, Schmidt I, et al. Implementing the World Health Organization surgical safety
checklist: a model for future perioperative initiatives. AORN J. 2011;94(6):590-8.
…
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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/41285/psn-pdf
June 01, 2012 - Effect of medication reconciliation at hospital admission
on medication discrepancies during hospitalization and at
discharge for geriatric patients.
June 1, 2012
Cornu P, Steurbaut S, Leysen T, et al. Effect of medication reconciliation at hospital admission on
medication discrepancies during hospitalization and …
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psnet.ahrq.gov/node/855107/psn-pdf
January 01, 2019 - Foundations of Safety Science: a century of
understanding accidents and disasters.
January 1, 2019
Dekker S. Taylor & Francis Group, Boca Raton, FL: CRC Press; 2019. ISBN: 9781138481787.
https://psnet.ahrq.gov/issue/foundations-safety-science-century-understanding-accidents-and-disasters
Safety science p…
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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/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/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/43321/psn-pdf
August 02, 2015 - Costs associated with surgical site infections in Veterans
Affairs hospitals.
August 2, 2015
Schweizer ML, Cullen JJ, Perencevich E, et al. Costs Associated With Surgical Site Infections in Veterans
Affairs Hospitals. JAMA Surg. 2014;149(6):575-81. doi:10.1001/jamasurg.2013.4663.
https://psnet.ahrq.gov/issue/costs…