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psnet.ahrq.gov/node/46428/psn-pdf
November 01, 2017 - Translating staff experience into organisational
improvement: the HEADS-UP stepped wedge, cluster
controlled, non-randomised trial.
November 1, 2017
Pannick S, Athanasiou T, Long SJ, et al. Translating staff experience into organisational improvement: the
HEADS-UP stepped wedge, cluster controlled, non-randomised …
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psnet.ahrq.gov/node/47359/psn-pdf
October 10, 2018 - Is there evidence of a July effect among patients
undergoing hysterectomy surgery?
October 10, 2018
Varma S, Mehta A, Hutfless S, et al. Is there evidence of a July effect among patients undergoing
hysterectomy surgery? Am J Obstet Gynecol. 2018;219(2):176.e1-176.e9. doi:10.1016/j.ajog.2018.05.033.
https://psnet.a…
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psnet.ahrq.gov/node/850173/psn-pdf
June 07, 2023 - A national safety board made transportation safer and
could do the same for health care, advocates say.
June 7, 2023
Jaklevic MC. CNN. May 30, 2023.
https://psnet.ahrq.gov/issue/national-safety-board-made-transportation-safer-and-could-do-same-health-
care-advocates-say
Patient safety has long drawn from aviation…
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psnet.ahrq.gov/node/838017/psn-pdf
September 07, 2022 - Addressing adultification of black pediatric patients in the
emergency department: a framework to decrease
disparities.
September 7, 2022
Koch A, Kozhumam A. Addressing adultification of black pediatric patients in the emergency department: a
framework to decrease disparities. Health Promot Pract. 2022;23(4):555-5…
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psnet.ahrq.gov/node/46032/psn-pdf
May 03, 2017 - Leveraging the Partnership for Patients' initiative to
improve patient safety and quality within the Military
Health System.
May 3, 2017
King HB, Kesling K, Birk C, et al. Leveraging the Partnership for Patients' Initiative to Improve Patient
Safety and Quality Within the Military Health System. Mil Med. 2017;182(…
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psnet.ahrq.gov/node/44470/psn-pdf
October 13, 2015 - Workplace training for senior trainees: a systematic
review and narrative synthesis of current approaches to
promote patient safety.
October 13, 2015
Walton M, Harrison R, Burgess A, et al. Workplace training for senior trainees: a systematic review and
narrative synthesis of current approaches to promote patient …
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psnet.ahrq.gov/node/43855/psn-pdf
April 15, 2016 - Perioperative safety in plastic surgery: is the World
Health Organization checklist useful in a broad practice?
April 15, 2016
Biskup N, Workman AD, Kutzner E, et al. Perioperative Safety in Plastic Surgery: Is the World Health
Organization Checklist Useful in a Broad Practice? Ann Plast Surg. 2016;76(5):550-5.
do…
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psnet.ahrq.gov/node/867759/psn-pdf
March 12, 2025 - Intrahospital patient transport: checklists, adverse
events, and other considerations for the anesthesia
professional.
March 12, 2025
Andrew C, Fitzsimons M. Intrahospital patient transport: checklists, adverse events, and other
considerations for the anesthesia professional. APSF Newsletter. 2025;40(1):24-26.
ht…
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psnet.ahrq.gov/node/45678/psn-pdf
October 11, 2017 - Is there a role for patients and their relatives in escalating
clinical deterioration in hospital? A systematic review.
October 11, 2017
Albutt AK, O'Hara JK, Conner MT, et al. Is there a role for patients and their relatives in escalating clinical
deterioration in hospital? A systematic review. Health Expect. 2017…
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psnet.ahrq.gov/node/73581/psn-pdf
January 01, 2022 - Applying human factors engineering to address the
telemetry alarm problem in a large medical center.
August 11, 2021
Patterson ES, Rayo MF, Edworthy JR, et al. Applying human factors engineering to address the telemetry
alarm problem in a large medical center. Hum Factors. 2022;64(1):126-142.
doi:10.1177/001872082…
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psnet.ahrq.gov/node/36333/psn-pdf
July 10, 2008 - The care transitions intervention: results of a randomized
controlled trial.
July 10, 2008
Coleman EA, Parry C, Chalmers S, et al. The care transitions intervention: results of a randomized
controlled trial. Arch Intern Med. 2006;166(17):1822-8.
https://psnet.ahrq.gov/issue/care-transitions-intervention-results-ra…
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psnet.ahrq.gov/node/44022/psn-pdf
May 28, 2015 - Initiatives to identify and mitigate medication errors in
England.
May 28, 2015
Cousins D, Gerrett D, Richards N, et al. Initiatives to identify and mitigate medication errors in England.
Drug Saf. 2015;38(4):349-357. doi:10.1007/s40264-015-0270-3.
https://psnet.ahrq.gov/issue/initiatives-identify-and-mitigate-med…
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psnet.ahrq.gov/node/44148/psn-pdf
November 06, 2015 - Role of cognition in generating and mitigating clinical
errors.
November 6, 2015
Patel VL, Kannampallil TG, Shortliffe EH. Role of cognition in generating and mitigating clinical errors. BMJ
Qual Saf. 2015;24(7):468-474. doi:10.1136/bmjqs-2014-003482.
https://psnet.ahrq.gov/issue/role-cognition-generating-and-miti…
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psnet.ahrq.gov/node/34649/psn-pdf
June 11, 2014 - On error management: lessons from aviation.
June 11, 2014
Helmreich RL. On error management: lessons from aviation. BMJ . 2000;320(7237):781-785.
https://psnet.ahrq.gov/issue/error-management-lessons-aviation
In this perspective, the author draws on analogies from aviation to frame the issues of patient safety and
…
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psnet.ahrq.gov/node/43909/psn-pdf
March 11, 2015 - Summary and frequency of barriers to adoption of CPOE
in the US.
March 11, 2015
Kruse CS, Goetz K. Summary and frequency of barriers to adoption of CPOE in the U.S. J Med Syst.
2015;39(2):15. doi:10.1007/s10916-015-0198-2.
https://psnet.ahrq.gov/issue/summary-and-frequency-barriers-adoption-cpoe-us
Although compu…
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psnet.ahrq.gov/node/864847/psn-pdf
March 20, 2024 - Inter-hospital transfer is an independent risk factor for
hospital-associated infection.
March 20, 2024
Gardner C, Rubinfeld IS, Gupta AH, et al. Inter-hospital transfer is an independent risk factor for hospital-
associated infection. Surg Infect (Larchmt). 2024;25(2):125-132. doi:10.1089/sur.2023.077.
https://ps…
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psnet.ahrq.gov/node/841486/psn-pdf
January 26, 2018 - Do words matter? Stigmatizing language and the
transmission of bias in the medical record.
January 26, 2018
P. Goddu A, O’Conor KJ, Lanzkron S, et al. Do words matter? Stigmatizing language and the transmission
of bias in the medical record. J Gen Intern Med. 2018;33(5):685-691. doi:10.1007/s11606-017-4289-2.
http…
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psnet.ahrq.gov/node/72821/psn-pdf
March 10, 2019 - I-PASS Mentored Implementation Handoff Curriculum:
implementation guide and resources.
March 10, 2019
O'Toole JK, Starmer AJ, Calaman S, et al. I-PASS Mentored Implementation Handoff Curriculum:
implementation guide and resources. MedEdPORTAL. 2018;14(1):10736. doi:10.15766/mep_2374-
8265.10736.
https://psnet.ahr…
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psnet.ahrq.gov/node/40061/psn-pdf
December 15, 2010 - Exploring relationships between hospital patient safety
culture and adverse events.
December 15, 2010
Mardon RE, Khanna K, Sorra J, et al. Exploring relationships between hospital patient safety culture and
adverse events. J Patient Saf. 2010;6(4):226-32. doi:10.1097/PTS.0b013e3181fd1a00.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/837853/psn-pdf
August 17, 2022 - RaDonda Vaught, medication safety, and the profession
of pharmacy: steps to improve safety and ensure justice.
August 17, 2022
Lambert BL, Schiff GD. RaDonda Vaught, medication safety, and the profession of pharmacy: steps to
improve safety and ensure justice. J Am Coll Clin Pharm. 2022;5(9):981-987. doi:10.1002/ja…