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psnet.ahrq.gov/node/43078/psn-pdf
June 03, 2014 - The value of autopsies in the era of high-tech medicine:
discrepant findings persist.
June 3, 2014
Kuijpers CCHJ, Fronczek J, van de Goot FRW, et al. The value of autopsies in the era of high-tech
medicine: discrepant findings persist. J Clin Pathol. 2014;67(6):512-9. doi:10.1136/jclinpath-2013-202122.
https://psn…
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psnet.ahrq.gov/node/45332/psn-pdf
August 27, 2018 - Guideline implementation: prevention of retained surgical
items.
August 27, 2018
Fencl JL. Guideline Implementation: Prevention of Retained Surgical Items. AORN J. 2016;104(1):37-48.
doi:10.1016/j.aorn.2016.05.005.
https://psnet.ahrq.gov/issue/guideline-implementation-prevention-retained-surgical-items
Although i…
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psnet.ahrq.gov/node/43811/psn-pdf
July 18, 2018 - 2014 Annual Benchmarking Report: Malpractice Risks in
the Diagnostic Process.
July 18, 2018
Hoffman J, ed. Cambridge, MA: CRICO Strategies; 2014.
https://psnet.ahrq.gov/issue/2014-annual-benchmarking-report-malpractice-risks-diagnostic-process
This analysis of more than 4700 diagnosis-related malpractice claims fo…
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psnet.ahrq.gov/node/47459/psn-pdf
October 10, 2018 - People, processes, health IT and accurate patient
identification.
October 10, 2018
Quick Safety. October 1, 2018;(45):1-2.
https://psnet.ahrq.gov/issue/people-processes-health-it-and-accurate-patient-identification
This newsletter article reviews common problems related to patient identification and recommends
st…
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psnet.ahrq.gov/node/43749/psn-pdf
December 10, 2014 - Alarm management: first things first: using reliable data
to eliminate unnecessary alarms.
December 10, 2014
Vanderveen T. Patient Saf Qual Healthc. November/December 2014;11:38-40,42-45.
https://psnet.ahrq.gov/issue/alarm-management-first-things-first-using-reliable-data-eliminate-unnecessary-
alarms
Spotlightin…
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psnet.ahrq.gov/node/41653/psn-pdf
December 30, 2014 - Impact of a hospital-wide hand hygiene initiative on
healthcare-associated infections: results of an interrupted
time series.
December 30, 2014
Kirkland KB, Homa KA, Lasky RA, et al. Impact of a hospital-wide hand hygiene initiative on healthcare-
associated infections: results of an interrupted time series. BMJ Q…
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psnet.ahrq.gov/node/43164/psn-pdf
May 03, 2016 - Patient safety in the era of healthcare reform.
May 3, 2016
Leape L. Patient safety in the era of healthcare reform. Clin Orthop Relat Res. 2015;473(5):1568-73.
doi:10.1007/s11999-014-3598-6.
https://psnet.ahrq.gov/issue/patient-safety-era-healthcare-reform
The publication of To Err Is Human spurred efforts to imp…
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psnet.ahrq.gov/node/44940/psn-pdf
September 20, 2016 - Dual-process cognitive interventions to enhance
diagnostic reasoning: a systematic review.
September 20, 2016
Lambe KA, O'Reilly G, Kelly BD, et al. Dual-process cognitive interventions to enhance diagnostic
reasoning: a systematic review. BMJ Qual Saf. 2016;25(10):808-820. doi:10.1136/bmjqs-2015-004417.
https://p…
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psnet.ahrq.gov/node/41541/psn-pdf
September 26, 2012 - Failures in communication and information transfer
across the surgical care pathway: interview study.
September 26, 2012
Nagpal K, Arora S, Vats A, et al. Failures in communication and information transfer across the surgical
care pathway: interview study. BMJ Qual Saf. 2012;21(10):843-9.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/43465/psn-pdf
February 18, 2015 - Hospital Readmissions Reduction Program: implications
for pharmacy.
February 18, 2015
Boesen KAG, Leal S, Sheehan VC, et al. Hospital Readmissions Reduction Program: implications for
pharmacy. Am J Health Syst Pharm. 2015;72(3):237-44. doi:10.2146/ajhp140177.
https://psnet.ahrq.gov/issue/hospital-readmissions-redu…
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psnet.ahrq.gov/node/73077/psn-pdf
March 24, 2021 - Well-Being Playbook 2.0. A COVID-19 Resource for
Hospital and Health System Leaders.
March 24, 2021
AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021.
https://psnet.ahrq.gov/issue/well-being-playbook-20-covid-19-resource-hospital-and-health-system-leaders
Human factors enginee…
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psnet.ahrq.gov/node/60615/psn-pdf
June 24, 2020 - Key potentially inappropriate drugs in pediatrics: the KIDs
list.
June 24, 2020
Meyers RS, Thackray J, Matson KL, et al. Key potentially inappropriate drugs in pediatrics: the KIDs list. J
Pediatr Pharmacol Ther. 2020;25(3). doi:10.5863/1551-6776-25.3.175.
https://psnet.ahrq.gov/issue/key-potentially-inappropriate…
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psnet.ahrq.gov/node/46501/psn-pdf
March 20, 2018 - Blind obedience and an unnecessary workup for
hypoglycemia: a teachable moment.
March 20, 2018
Wang EY, Patrick L, Connor DM. Blind Obedience and an Unnecessary Workup for Hypoglycemia: A
Teachable Moment. JAMA Intern Med. 2018;178(2):279-280. doi:10.1001/jamainternmed.2017.7104.
https://psnet.ahrq.gov/issue/blind…
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psnet.ahrq.gov/node/37336/psn-pdf
January 05, 2012 - 'My five moments for hand hygiene': a user-centred
design approach to understand, train, monitor and report
hand hygiene.
January 5, 2012
Sax H, Allegranzi B, Uçkay I, et al. 'My five moments for hand hygiene': a user-centred design approach to
understand, train, monitor and report hand hygiene. J Hosp Infect. 200…
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psnet.ahrq.gov/node/74186/psn-pdf
January 01, 2022 - Staffing, teamwork and scope of practice: analysis of the
association with patient safety in the context of
rehabilitation.
December 15, 2021
Jomaa C, Dubois C?A, Caron I, et al. Staffing, teamwork and scope of practice: analysis of the association
with patient safety in the context of rehabilitation. J Adv Nurs. …
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psnet.ahrq.gov/node/45035/psn-pdf
January 23, 2017 - Premature closure? Not so fast.
January 23, 2017
Dhaliwal G. Premature closure? Not so fast. BMJ Qual Saf. 2017;26(2):87-89. doi:10.1136/bmjqs-2016-
005267.
https://psnet.ahrq.gov/issue/premature-closure-not-so-fast
Analyzing clinician decision making is increasingly suggested as a strategy to reduce diagnostic er…
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psnet.ahrq.gov/node/45010/psn-pdf
March 30, 2016 - Most dangerous time at the hospital? It may be when you
leave.
March 30, 2016
Khullar D. New York Times. March 17, 2016.
https://psnet.ahrq.gov/issue/most-dangerous-time-hospital-it-may-be-when-you-leave
Preventing readmissions after hospital discharge is a national policy priority. This newspaper article
discuss…
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psnet.ahrq.gov/node/37879/psn-pdf
July 02, 2008 - Work hour rules and contributors to patient care
mistakes: a focus group study with internal medicine
residents.
July 2, 2008
Fletcher KE, Parekh V, Halasyamani L, et al. Work hour rules and contributors to patient care mistakes: a
focus group study with internal medicine residents. J Hosp Med. 2008;3(3):228-37. d…
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psnet.ahrq.gov/node/840163/psn-pdf
November 16, 2022 - Deep Dive: Racial and Ethnic Disparities in Health and
Healthcare.
November 16, 2022
Plymouth Meeting, PA: ECRI and the Institute for Safe Medication Practices; 2022.
https://psnet.ahrq.gov/issue/deep-dive-racial-and-ethnic-disparities-health-and-healthcare
Racist behavior directed at either patients or clinicians…
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psnet.ahrq.gov/node/72499/psn-pdf
November 25, 2020 - Transformational improvement in quality care and health
systems: the next decade.
November 25, 2020
Braithwaite J, Vincent CA, Garcia-Elorrio E, et al. Transformational improvement in quality care and health
systems: the next decade. BMC Med. 2020;18(1):340. doi:10.1186/s12916-020-01739-y.
https://psnet.ahrq.gov/i…