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psnet.ahrq.gov/node/851461/psn-pdf
July 19, 2023 - Patient safety 2.0: slaying dragons, not just investigating
them.
July 19, 2023
Card AJ. Patient safety 2.0: slaying dragons, not just investigating them. J Patient Saf. 2023;19(6):394-395.
doi:10.1097/pts.0000000000001140.
https://psnet.ahrq.gov/issue/patient-safety-20-slaying-dragons-not-just-investigating-them
…
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psnet.ahrq.gov/node/42468/psn-pdf
August 07, 2013 - A comprehensive quality assurance program for
personnel and procedures in radiation oncology: value of
voluntary error reporting and checklists.
August 7, 2013
Kalapurakal JA, Zafirovski A, Smith J, et al. A comprehensive quality assurance program for personnel and
procedures in radiation oncology: value of volunt…
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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/839327/psn-pdf
December 05, 2024 - The National Healthcare System Action Alliance for
Patient and Workforce Safety.
December 5, 2024
US Department of Health and Human Services.
https://psnet.ahrq.gov/issue/national-healthcare-system-action-alliance-advance-patient-safety
The large system change required to reduce patient harm requires multi-stakeho…
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psnet.ahrq.gov/node/836761/psn-pdf
March 16, 2022 - Complexity bias in the prevention of iatrogenic injury:
why specific harms may inhibit performance.
March 16, 2022
Padula WV, Armstrong DG, Goldman DP. Complexity bias in the prevention of iatrogenic injury: why
specific harms may inhibit performance. Mayo Clin Proc. 2022;97(2):221-224.
doi:10.1016/j.mayocp.2021.1…
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psnet.ahrq.gov/node/47851/psn-pdf
May 22, 2019 - Communication and Resolution After an Adverse Health
Care Incident.
May 22, 2019
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
https://psnet.ahrq.gov/issue/communication-and-resolution-after-adverse-health-care-incident
Communication-and-resolution mechanisms are seen as important approache…
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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/46483/psn-pdf
October 04, 2017 - Fall Prevention in Hospitals Training Program.
October 4, 2017
Rockville, MD: Agency for Healthcare Research and Quality; 2017.
https://psnet.ahrq.gov/issue/fall-prevention-hospitals-training-program
Falls are a primary focus of quality and patient safety improvement efforts in hospitals. This training
program pro…
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psnet.ahrq.gov/node/45273/psn-pdf
October 13, 2018 - Using an inpatient portal to engage families in pediatric
hospital care.
October 13, 2018
Kelly MM, Hoonakker P, Dean SM. Using an inpatient portal to engage families in pediatric hospital care. J
Am Med Inform Assoc. 2017;24(1):153-161. doi:10.1093/jamia/ocw070.
https://psnet.ahrq.gov/issue/using-inpatient-portal…
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psnet.ahrq.gov/node/862151/psn-pdf
February 07, 2024 - Taking up the challenge to improve name and role
recognition in the operating room.
February 7, 2024
Thota B, Rabinowitz A, Guttman OT. Taking up the challenge to improve name and role recognition in the
operating room. J Patient Saf. 2024;20(1):45-47. doi:10.1097/pts.0000000000001177.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/74848/psn-pdf
February 16, 2022 - Patients for Patient Safety US.
February 16, 2022
404.510.8787; info@pfps.us
https://psnet.ahrq.gov/issue/patients-patient-safety-us
Patient safety improvement has made progress but more can be done. This organization supports
community efforts in the United States to engage policymakers in work toward aligning ef…
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psnet.ahrq.gov/node/841492/psn-pdf
December 14, 2022 - Cybersecurity is Patient Safety: Policy Options in the
Health Care Sector.
December 14, 2022
Washington DC; Office of Senator Mark Warner: November 25, 2022.
https://psnet.ahrq.gov/issue/cybersecurity-patient-safety-policy-options-health-care-sector
There is lack of consensus concerning the need for increased syst…
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psnet.ahrq.gov/node/34981/psn-pdf
July 14, 2010 - Child-specific risk factors and patient safety.
July 14, 2010
Woods DM, Holl JL, Shonkoff JP, et al. J Patient Saf. 2005;1(1):17-22.
https://psnet.ahrq.gov/issue/child-specific-risk-factors-and-patient-safety
To discover factors that may contribute to a child’s risk for error during hospitalization, this study iden…
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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/838196/psn-pdf
July 01, 2019 - The impact of racism on child and adolescent health.
July 1, 2019
Trent M, Dooley DG, Dougé J, et al. The impact of racism on child and adolescent health. Pediatrics.
2019;144(2):e20191765. doi:10.1542/peds.2019-1765.
https://psnet.ahrq.gov/issue/impact-racism-child-and-adolescent-health
Children and adolescents a…
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psnet.ahrq.gov/node/46524/psn-pdf
October 18, 2017 - Pressure Injury Prevention in Hospitals Training Program.
October 18, 2017
Rockville, MD: Agency for Healthcare Research and Quality; September 2017.
https://psnet.ahrq.gov/issue/pressure-injury-prevention-hospitals-training-program
Pressure ulcers are a common hospital-acquired condition that can lead to patient h…
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psnet.ahrq.gov/node/41536/psn-pdf
December 31, 2014 - Retail pharmacy staff perceptions of design strengths and
weaknesses of electronic prescribing.
December 31, 2014
Odukoya OK, Chui MA. Retail pharmacy staff perceptions of design strengths and weaknesses of
electronic prescribing. J Am Med Inform Assoc. 2012;19(6):1059-65. doi:10.1136/amiajnl-2011-000779.
https://…
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psnet.ahrq.gov/node/39789/psn-pdf
August 25, 2010 - Using evidence, rigorous measurement, and collaboration
to eliminate central catheter-associated bloodstream
infections.
August 25, 2010
Sawyer M, Weeks K, Goeschel CA, et al. Using evidence, rigorous measurement, and collaboration to
eliminate central catheter-associated bloodstream infections. Crit Care Med. 201…
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psnet.ahrq.gov/node/73415/psn-pdf
June 23, 2021 - Patient safety in dermatology: a ten-year update.
June 23, 2021
Patel J, Otto E, Taylor JS, et al. Dermatol Online J. 2021;27(3).
https://psnet.ahrq.gov/issue/patient-safety-dermatology-ten-year-update
In an update to their 2010 article, this review’s authors summarized the patient safety literature in
dermatology…
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psnet.ahrq.gov/node/46742/psn-pdf
March 14, 2018 - Evidence-based guidelines for fatigue risk management in
emergency medical services.
March 14, 2018
Patterson D, Higgins S, Van Dongen HPA, et al. Evidence-Based Guidelines for Fatigue Risk Management
in Emergency Medical Services. Prehosp Emerg Care. 2018;22(sup1):89-101.
doi:10.1080/10903127.2017.1376137.
https…