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psnet.ahrq.gov/node/45228/psn-pdf
June 29, 2016 - An innovative approach to the surgical time out: a patient-
focused model.
June 29, 2016
Kozusko SD, Elkwood L, Gaynor D, et al. An Innovative Approach to the Surgical Time Out: A Patient-
Focused Model. AORN J. 2016;103(6):617-22. doi:10.1016/j.aorn.2016.04.001.
https://psnet.ahrq.gov/issue/innovative-approach-su…
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psnet.ahrq.gov/node/844748/psn-pdf
February 15, 2023 - 'They were his best shot. And they failed to help’: why did
EMS workers neglect Tyre Nichols?
February 15, 2023
Renault M. STAT. February 6, 2023.
https://psnet.ahrq.gov/issue/they-were-his-best-shot-and-they-failed-help-why-did-ems-workers-neglect-
tyre-nichols
Emergent care situations are vulnerable to a range …
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psnet.ahrq.gov/node/865978/psn-pdf
May 29, 2024 - Ensuring safe and equitable discharge: a quality
improvement initiative for individuals with hypertensive
disorders of pregnancy.
May 29, 2024
Zacherl KM, Sterrett EC, Hughes BL, et al. Ensuring safe and equitable discharge: a quality improvement
initiative for individuals with hypertensive disorders of pregnancy.…
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psnet.ahrq.gov/node/46633/psn-pdf
November 22, 2017 - The high costs of unnecessary care.
November 22, 2017
Carroll AE. The High Costs of Unnecessary Care. JAMA. 2017;318(18):1748-1749.
doi:10.1001/jama.2017.16193.
https://psnet.ahrq.gov/issue/high-costs-unnecessary-care
The provision of unneeded care can result in physical, financial, and psychological harm to patie…
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psnet.ahrq.gov/node/843087/psn-pdf
January 25, 2023 - Interventions to increase patient safety in long-term care
facilities-umbrella review.
January 25, 2023
?witalski J, Wnuk K, Tatara T, et al. Interventions to increase patient safety in long-term care facilities-
umbrella review. Int J Environ Res Public Health. 2022;19(22):15354. doi:10.3390/ijerph192215354.
http…
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psnet.ahrq.gov/node/47503/psn-pdf
October 24, 2018 - I-PASS checklist: a powerful tool for patient handoffs.
October 24, 2018
Peeples L. Pharmacy Practice News. October 10, 2018.
https://psnet.ahrq.gov/issue/i-pass-checklist-powerful-tool-patient-handoffs
Structured handoffs can reduce communication problems that contribute to medical error. This magazine
article re…
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psnet.ahrq.gov/node/47154/psn-pdf
May 23, 2018 - Comparison of military and civilian methods for
determining potentially preventable deaths: a systematic
review.
May 23, 2018
Janak JC, Sosnov JA, Bares JM, et al. Comparison of Military and Civilian Methods for Determining
Potentially Preventable Deaths: A Systematic Review. JAMA Surg. 2018;153(4):367-375.
doi:1…
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psnet.ahrq.gov/node/40622/psn-pdf
September 25, 2011 - Alternatives to potentially inappropriate medications for
use in e-prescribing software: triggers and treatment
algorithms.
September 25, 2011
Hume AL, Quilliam BJ, Goldman R, et al. Alternatives to potentially inappropriate medications for use in e-
prescribing software: triggers and treatment algorithms. BMJ Qua…
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psnet.ahrq.gov/node/47271/psn-pdf
August 08, 2018 - NAM Action Collaborative on Countering the U.S. Opioid
Epidemic.
August 8, 2018
National Academy of Medicine; Aspen Institute.
https://psnet.ahrq.gov/issue/nam-action-collaborative-countering-us-opioid-epidemic
Despite increased awareness regarding the public health impacts of opioid misuse and overdose in the
Un…
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psnet.ahrq.gov/node/47800/psn-pdf
June 26, 2019 - Error and Uncertainty in Diagnostic Radiology.
June 26, 2019
Bruno MA. New York, NY: Oxford University Press; 2019. ISBN: 9780190665395.
https://psnet.ahrq.gov/issue/error-and-uncertainty-diagnostic-radiology
Despite enhancements in medical imaging technology, diagnostic radiologists are still susceptible to
uncer…
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psnet.ahrq.gov/node/837340/psn-pdf
June 08, 2022 - Wellbeing, burnout, and safe practice among healthcare
professionals: predictive influences of mindfulness,
values, and self-compassion.
June 8, 2022
Prudenzi A, D. Graham C, Flaxman PE, et al. Wellbeing, burnout, and safe practice among healthcare
professionals: predictive influences of mindfulness, values, and s…
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psnet.ahrq.gov/node/48036/psn-pdf
July 10, 2019 - Can positivity promote safety? Psychological capital
development combats cynicism and unsafe behavior.
July 10, 2019
Stratman JL, Youssef-Morgan CM. Can positivity promote safety? Psychological capital development
combats cynicism and unsafe behavior. Safety Sci. 2019;116:13-25. doi:10.1016/j.ssci.2019.02.031.
htt…
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psnet.ahrq.gov/node/45376/psn-pdf
November 09, 2016 - The new CMS hospital quality star ratings: the stars are
not aligned.
November 9, 2016
Bilimoria KY, Barnard C. The New CMS Hospital Quality Star Ratings: The Stars Are Not Aligned. JAMA.
2016;316(17):1761-1762. doi:10.1001/jama.2016.13679.
https://psnet.ahrq.gov/issue/new-cms-hospital-quality-star-ratings-stars-a…
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psnet.ahrq.gov/node/47087/psn-pdf
May 02, 2018 - The Economics of Patient Safety in Primary and
Ambulatory Care: Flying Blind.
May 2, 2018
Slawomirski L, Auraaen A, Klazinga N. Paris, France: Organisation for Economic Co-operation and
Development; 2018.
https://psnet.ahrq.gov/issue/economics-patient-safety-primary-and-ambulatory-care-flying-blind
The global eco…
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psnet.ahrq.gov/node/44791/psn-pdf
January 13, 2016 - FDA Drug Safety Communication: FDA cautions about
dosing errors when switching between different oral
formulations of antifungal Noxafil (posaconazole); label
changes approved.
January 13, 2016
US Food and Drug Administration; FDA.
https://psnet.ahrq.gov/issue/fda-drug-safety-communication-fda-cautions-about-dosi…
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psnet.ahrq.gov/node/60286/psn-pdf
April 29, 2020 - With Covid-19 delaying routine care, chronic disease
startups brace for a slew of complications.
April 29, 2020
Brodwin E. STAT. April 14, 2020.
https://psnet.ahrq.gov/issue/covid-19-delaying-routine-care-chronic-disease-startups-brace-slew-
complications
Patients with cancer and other chronic disorder treatment …
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psnet.ahrq.gov/node/46758/psn-pdf
April 12, 2019 - Association of hospitalist years of experience with
mortality in the hospitalized Medicare population.
April 12, 2019
Goodwin JS, Salameh H, Zhou J, et al. Association of Hospitalist Years of Experience With Mortality in the
Hospitalized Medicare Population. JAMA Intern Med. 2017;178(2). doi:10.1001/jamainternmed.2…
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psnet.ahrq.gov/node/47270/psn-pdf
August 08, 2018 - A method to identify pediatric high-risk diagnoses missed
in the emergency department.
August 8, 2018
Sundberg M, Perron CO, Kimia A, et al. A method to identify pediatric high-risk diagnoses missed in the
emergency department. Diagnosis (Berl). 2018;5(2):63-69. doi:10.1515/dx-2018-0005.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/73522/psn-pdf
July 21, 2021 - Federal speech rulings may embolden health care
workers to call out safety issues.
July 21, 2021
Meyer H. Kaiser Health News. July 9, 2021.
https://psnet.ahrq.gov/issue/federal-speech-rulings-may-embolden-health-care-workers-call-out-safety-
issues
Whistleblower protections are a key component to raising awarenes…
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psnet.ahrq.gov/node/72778/psn-pdf
February 24, 2021 - Distractions in the cardiac catheterisation laboratory:
impact for cardiologists and patient safety.
February 24, 2021
Mahadevan K, Cowan E, Kalsi N, et al. Distractions in the cardiac catheterisation laboratory: impact for
cardiologists and patient safety. Open Heart. 2020;7(2). doi:10.1136/openhrt-2020-001260.
h…