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psnet.ahrq.gov/node/44386/psn-pdf
August 12, 2015 - Using simulation to improve systems.
August 12, 2015
Lundberg PW, Korndorffer JR. Using Simulation to Improve Systems. Surg Clin North Am. 2015;95(4):885-
92. doi:10.1016/j.suc.2015.04.007.
https://psnet.ahrq.gov/issue/using-simulation-improve-systems
Safety approaches from aviation that can be applied to health c…
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psnet.ahrq.gov/node/46206/psn-pdf
August 02, 2017 - Patient safety in dentistry: development of a candidate
'never event' list for primary care.
August 2, 2017
Black I, Bowie P. Patient safety in dentistry: development of a candidate 'never event' list for primary care.
Br Dent J. 2017;222(10):782-788. doi:10.1038/sj.bdj.2017.456.
https://psnet.ahrq.gov/issue/patie…
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psnet.ahrq.gov/node/46988/psn-pdf
April 25, 2018 - Opioid Stewardship.
April 25, 2018
Ochsner J. 2018;18(1):20-45.
https://psnet.ahrq.gov/issue/opioid-stewardship
Both organizational and national strategies are required to reduce opioid-related harm. This special issue
section explores one health system's efforts to address the opioid epidemic. Articles discuss em…
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psnet.ahrq.gov/node/867686/psn-pdf
March 05, 2025 - Association between surgeon stress and major surgical
complications.
March 5, 2025
Awtry J, Skinner S, Polazzi S, et al. Association between surgeon stress and major surgical complications.
JAMA Surg. 2025;160(3):332-340. doi:10.1001/jamasurg.2024.6072.
https://psnet.ahrq.gov/issue/association-between-surgeon-stre…
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psnet.ahrq.gov/node/48045/psn-pdf
June 05, 2019 - Obstetric practice guidelines: labor's love lost?
June 5, 2019
Cohen WR, Friedman EA. Obstetric practice guidelines: labor's love lost? J Matern Fetal Neonatal Med.
2019;32(9):1567-1570. doi:10.1080/14767058.2017.1406474.
https://psnet.ahrq.gov/issue/obstetric-practice-guidelines-labors-love-lost
Guidelines play a…
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psnet.ahrq.gov/node/34062/psn-pdf
February 18, 2011 - Adverse drug events in ambulatory care.
February 18, 2011
Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. New Engl J Med.
2003;348(16):1556-1564.
https://psnet.ahrq.gov/issue/adverse-drug-events-ambulatory-care
This prospective cohort study evaluated more than 1200 outpatient prescr…
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psnet.ahrq.gov/node/39121/psn-pdf
March 04, 2011 - The influence that electronic prescribing has on
medication errors and preventable adverse drug events:
an interrupted time-series study.
March 4, 2011
van Doormaal J, van den Bemt PMLA, Zaal RJ, et al. The influence that electronic prescribing has on
medication errors and preventable adverse drug events: an inter…
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psnet.ahrq.gov/node/73569/psn-pdf
August 04, 2021 - Enabling a learning healthcare system with automated
computer protocols that produce replicable and
personalized clinician actions.
August 4, 2021
Morris AH, Stagg B, Lanspa M, et al. Enabling a learning healthcare system with automated computer
protocols that produce replicable and personalized clinician actions.…
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psnet.ahrq.gov/node/846164/psn-pdf
March 15, 2023 - Crowding in the Emergency Department: Challenges for
the Care of Children.
March 15, 2023
Gross TK, Lane NE, Timm NL, et al. Crowding in the Emergency Department: Challenges for the Care of
Children. Pediatrics. 2023;151(3):e2022060971-e2022060972. doi:10.1542/peds.2022-060971.
https://psnet.ahrq.gov/issue/crowdin…
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psnet.ahrq.gov/node/60992/psn-pdf
October 14, 2020 - Another medical malpractice crisis?: Try something
different.
October 14, 2020
Sage WM, Boothman RC, Gallagher TH. Another medical malpractice crisis?: Try something different.
JAMA. 2020;324(14):1395-1396. doi:10.1001/jama.2020.16557.
https://psnet.ahrq.gov/issue/another-medical-malpractice-crisis-try-something-d…
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psnet.ahrq.gov/node/863757/psn-pdf
March 06, 2024 - Debriefing to improve interprofessional teamwork in the
operating room: a systematic review.
March 6, 2024
Skegg E, McElroy C, Mudgway M, et al. Debriefing to improve interprofessional teamwork in the operating
room: a systematic review. J Nurs Scholarsh. 2023;55(6):1179-1188. doi:10.1111/jnu.12924.
https://psnet.…
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psnet.ahrq.gov/node/857459/psn-pdf
December 06, 2023 - Five strategies for a safer EHR modernization journey.
December 6, 2023
Sittig DF, Yackel EE, Singh H. Five strategies for a safer EHR modernization journey. J Gen Intern Med.
2023;38(S4):940-942. doi:10.1007/s11606-023-08331-z.
https://psnet.ahrq.gov/issue/five-strategies-safer-ehr-modernization-journey
Large-sca…
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psnet.ahrq.gov/node/60032/psn-pdf
March 11, 2020 - Medical teamwork and the evolution of safety science: a
critical review.
March 11, 2020
Neuhaus C, Lutnæs DE, Bergström J. Medical teamwork and the evolution of safety science: a critical
review. Cogn Technol Work. 2020;22(1):13-27. doi:10.1007/s10111-019-00545-8.
https://psnet.ahrq.gov/issue/medical-teamwork-and-…
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psnet.ahrq.gov/node/40892/psn-pdf
February 06, 2012 - Four years' experience with a hospitalist-led medical
emergency team: an interrupted time series.
February 6, 2012
Rothberg MB, Belforti R, Fitzgerald J, et al. Four years' experience with a hospitalist-led medical
emergency team: an interrupted time series. J Hosp Med. 2012;7(2):98-103. doi:10.1002/jhm.953.
https…
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psnet.ahrq.gov/node/47738/psn-pdf
February 06, 2019 - ISMP Guidelines for Safe Electronic Communication of
Medication Information.
February 6, 2019
Horsham, PA: Institute for Safe Medication Practices; January 2019.
https://psnet.ahrq.gov/issue/ismp-guidelines-safe-electronic-communication-medication-information
Inaccurate or incomplete data in electronic health reco…
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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…
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psnet.ahrq.gov/node/838623/psn-pdf
October 19, 2022 - Resident and nurse perspectives on the use of secure
text messaging systems.
October 19, 2022
Aziz S, Barber J, Singh A, et al. Resident and nurse perspectives on the use of secure text messaging
systems. J Hosp Med. 2022;17(11):880-887. doi:10.1002/jhm.12953.
https://psnet.ahrq.gov/issue/resident-and-nurse-perspe…
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psnet.ahrq.gov/node/47646/psn-pdf
February 06, 2019 - Systematic review of computerized prescriber order entry
and clinical decision support.
February 6, 2019
Vélez-Díaz-Pallarés M, Pérez-Menéndez-Conde C, Bermejo-Vicedo T. Systematic review of computerized
prescriber order entry and clinical decision support. Am J Health Syst Pharm. 2018;75(23):1909-1921.
doi:10.214…
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psnet.ahrq.gov/node/34643/psn-pdf
December 23, 2008 - The health care cost of drug-related morbidity and
mortality in nursing facilities.
December 23, 2008
Bootman JL, Harrison DL, Cox E. The health care cost of drug-related morbidity and mortality in nursing
facilities. Arch Intern Med. 1997;157(18):2089-96.
https://psnet.ahrq.gov/issue/health-care-cost-drug-related…
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psnet.ahrq.gov/node/43478/psn-pdf
August 27, 2014 - Is it time to move beyond errors in clinical reasoning and
discuss accuracy?
August 27, 2014
Wood TJ. Is it time to move beyond errors in clinical reasoning and discuss accuracy? Adv Health Sci Educ
Theory Pract. 2014;19(3):403-407. doi:10.1007/s10459-014-9498-4.
https://psnet.ahrq.gov/issue/it-time-move-beyond-er…