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psnet.ahrq.gov/node/862130/psn-pdf
February 07, 2024 - Interventions to support nurses as second victims of
patient safety incidents: a qualitative study of nurse
managers' perceptions.
February 7, 2024
Järvisalo P, Haatainen K, Von Bonsdorff M, et al. Interventions to support nurses as second victims of
patient safety incidents: a qualitative study of nurse managers'…
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psnet.ahrq.gov/node/73621/psn-pdf
August 25, 2021 - Association of dose tapering with overdose or mental
health crisis among patients prescribed long-term
opioids.
August 25, 2021
Agnoli A, Xing G, Tancredi DJ, et al. Association of dose tapering with overdose or mental health crisis
among patients prescribed long-term opioids. JAMA. 2021;326(5):411-419. doi:10.100…
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psnet.ahrq.gov/node/853614/psn-pdf
September 20, 2023 - Towards diagnostic excellence on academic ward teams:
building a conceptual model of team dynamics in the
diagnostic process.
September 20, 2023
Choi JJ, Rosen MA, Shapiro MF, et al. Towards diagnostic excellence on academic ward teams: building a
conceptual model of team dynamics in the diagnostic process. Diagno…
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psnet.ahrq.gov/node/47368/psn-pdf
September 12, 2018 - Using co-design to develop a collective leadership
intervention for healthcare teams to improve safety
culture.
September 12, 2018
Ward ME, De Brún A, Beirne D, et al. Using Co-Design to Develop a Collective Leadership Intervention for
Healthcare Teams to Improve Safety Culture. Int J Environ Res Public Health. 20…
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psnet.ahrq.gov/node/837634/psn-pdf
July 06, 2022 - Patient safety trends in 2021: an analysis of 288,882
serious events and incidents from the nation’s largest
event reporting database.
July 6, 2022
Kepner S, Jones RM. Patient safety trends in 2021: an analysis of 288,882 serious events and incidents
from the nation’s largest event reporting database. Patient Saf.…
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pso.ahrq.gov/pso/listed/geographic
October 01, 2022 - SHARE:
Map of PSOs
There are 116 PSOs
in 37 States and the District of Columbia. This map shows the physical location of each PSO. All PSOs can operate nationally regardless of their home state.
Note: AHRQ updates…
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psnet.ahrq.gov/node/46618/psn-pdf
June 25, 2018 - Identifying quality markers of a safe surgical ward: an
interview study of patients, clinical staff, and
administrators.
June 25, 2018
Hassen Y, Singh P, Pucher PH, et al. Identifying quality markers of a safe surgical ward: An interview study
of patients, clinical staff, and administrators. Surgery. 2018;163(6):1…
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psnet.ahrq.gov/node/45680/psn-pdf
February 22, 2017 - Pediatric medication safety in adult community hospital
settings: a glimpse into nationwide practice.
February 22, 2017
Alvarez F, Ismail L, Markowsky A. Pediatric Medication Safety in Adult Community Hospital Settings: A
Glimpse Into Nationwide Practice. Hosp Pediatr. 2016;6(12):744-749.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/47911/psn-pdf
April 03, 2019 - Second victims need emotional support after adverse
events: even in a just safety culture.
April 3, 2019
Schrøder K, Lamont RF, Jørgensen JS, et al. Second victims need emotional support after adverse events:
even in a just safety culture. BJOG. 2019;126(4):440-442. doi:10.1111/1471-0528.15529.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/48178/psn-pdf
January 01, 2020 - ACR guidance document on MR safe practices: updates
and critical information 2019.
August 14, 2019
ACR Committee on MR Safety, Greenberg TD, Hoff MN, Gilk TB, et al. J Magn Reson Imaging.
2020;51(2):331-338.
https://psnet.ahrq.gov/issue/acr-guidance-document-mr-safe-practices-updates-and-critical-inform…
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psnet.ahrq.gov/node/44599/psn-pdf
December 09, 2015 - Association between day of delivery and obstetric
outcomes: observational study.
December 9, 2015
Palmer WL, Bottle A, Aylin P. Association between day of delivery and obstetric outcomes: observational
study. BMJ. 2015;351:h5774. doi:10.1136/bmj.h5774.
https://psnet.ahrq.gov/issue/association-between-day-delivery-…
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psnet.ahrq.gov/node/844038/psn-pdf
January 01, 2024 - The effectiveness of tele-triage during the COVID-19
pandemic: a systematic review and narrative synthesis.
February 8, 2023
Farzandipour M, Nabovati E, Sharif R. The effectiveness of tele-triage during the COVID-19 pandemic: a
systematic review and narrative synthesis. J Telemed Telecare. 2024;30(9):1367-1375.
do…
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psnet.ahrq.gov/node/47952/psn-pdf
January 01, 2020 - Overlooked guide wire: a multicomplicated Swiss Cheese
Model example. Analysis of a case and review of the
literature.
May 15, 2019
Thonon H, Espeel F, Frederic F, et al. Overlooked guide wire: a multicomplicated Swiss Cheese Model
example. Analysis of a case and review of the literature. Acta Clin Belg. 2020;75(3…
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psnet.ahrq.gov/node/73073/psn-pdf
January 01, 2022 - Crossing academic boundaries for diagnostic safety: 10
complex challenges and potential solutions from clinical
perspectives and high-reliability organizing principles.
March 24, 2021
Yousef EA, Sutcliffe KM, McDonald KM, et al. Crossing academic boundaries for diagnostic safety: 10
complex challenges and potentia…
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psnet.ahrq.gov/node/836760/psn-pdf
March 16, 2022 - Comprehensive Healthcare Inspection Summary Report:
Evaluation of Mental Health in Veterans Health
Administration Facilities, Fiscal Year 2020.
March 16, 2022
Washington, DC: VA Office of the Inspector General; February 17, 2022. Report No. 21-01506-76.
https://psnet.ahrq.gov/issue/comprehensive-healthcare-i…
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psnet.ahrq.gov/node/37022/psn-pdf
September 24, 2010 - Implementation and impact of a rapid response team in a
children's hospital.
September 24, 2010
Zenker P, Schlesinger A, Hauck M, et al. Implementation and impact of a rapid response team in a
children's hospital. Jt Comm J Qual Patient Saf. 2007;33(7):418-425.
https://psnet.ahrq.gov/issue/implementation-and-impac…
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psnet.ahrq.gov/node/40940/psn-pdf
December 31, 2011 - New 2011 survey of patients with complex care needs in
eleven countries finds that care is often poorly
coordinated.
December 31, 2011
Schoen C, Osborn R, Squires D, et al. New 2011 survey of patients with complex care needs in eleven
countries finds that care is often poorly coordinated. Health Aff (Millwood). 20…
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psnet.ahrq.gov/node/39932/psn-pdf
October 20, 2010 - Incorrect surgical counts: a qualitative analysis.
October 20, 2010
Rowlands A, Steeves R. Incorrect surgical counts: a qualitative analysis. AORN J. 2010;92(4):410-9.
doi:10.1016/j.aorn.2010.01.019.
https://psnet.ahrq.gov/issue/incorrect-surgical-counts-qualitative-analysis
Preventing surgical instruments from be…
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psnet.ahrq.gov/node/44104/psn-pdf
July 16, 2015 - Errors upstream and downstream to the Universal
Protocol associated with wrong surgery events in the
Veterans Health Administration.
July 16, 2015
Paull DE, Mazzia L, Neily J, et al. Errors upstream and downstream to the Universal Protocol associated
with wrong surgery events in the Veterans Health Administration.…
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psnet.ahrq.gov/node/840142/psn-pdf
November 16, 2022 - The neglected barrier to medication use: a systematic
review of difficulties associated with opening medication
packaging.
November 16, 2022
Angel M, Bechard L, Pua YH, et al. The neglected barrier to medication use: a systematic review of
difficulties associated with opening medication packaging. Age Ageing. 2022…