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psnet.ahrq.gov/node/73466/psn-pdf
July 07, 2021 - COVID-19 and open notes: a new method to enhance
patient safety and trust.
July 7, 2021
Blease CR, Salmi L, Hägglund M, et al. COVID-19 and open notes: a new method to enhance patient
safety and trust. JMIR Ment Health. 2021;8(6):e29314. doi:10.2196/29314.
https://psnet.ahrq.gov/issue/covid-19-and-open-notes-new-m…
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psnet.ahrq.gov/node/47184/psn-pdf
August 08, 2018 - Delivering on the promise of CLER: a patient safety
rotation that aligns resident education with hospital
processes.
August 8, 2018
Patel E, Muthusamy V, Young JQ. Delivering on the Promise of CLER: A Patient Safety Rotation That
Aligns Resident Education With Hospital Processes. Acad Med. 2018;93(6):898-903.
doi…
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psnet.ahrq.gov/node/841762/psn-pdf
December 21, 2022 - Strategies for a safe interhospital transfer with an
intubated patient or where readiness for intubation is
needed: a critical incidents study.
December 21, 2022
Almqvist D, Norberg D, Larsson F, et al. Strategies for a safe interhospital transfer with an intubated patient
or where readiness for intubation is need…
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psnet.ahrq.gov/node/849128/psn-pdf
May 17, 2023 - Is primary care a patient-safe setting? Prevalence,
severity, nature, and causes of adverse events: numerous
and mostly avoidable.
May 17, 2023
Garzón González G, Alonso Safont T, Zamarrón Fraile E, et al. Is primary care a patient-safe setting?
Prevalence, severity, nature, and causes of adverse events: numerous …
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psnet.ahrq.gov/node/35300/psn-pdf
March 04, 2011 - How strong is the evidence for the use of perioperative
beta blockers in non-cardiac surgery? Systematic review
and meta-analysis of randomised controlled trials.
March 4, 2011
Devereaux PJ, Beattie WS, Choi PT-L, et al. How strong is the evidence for the use of perioperative ?
blockers in non-cardiac surgery? Sys…
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psnet.ahrq.gov/node/836723/psn-pdf
March 09, 2022 - Morbidity and mortality caused by noncompliance with
California hospital licensure: immediate jeopardies in
California hospitals, 2007-2017.
March 9, 2022
Zheng MY, Lui H, Patino G, et al. Morbidity and mortality caused by noncompliance with California hospital
licensure: immediate jeopardies in California hospita…
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psnet.ahrq.gov/node/47711/psn-pdf
June 14, 2019 - Type 1 diabetes defined by severe insulin deficiency
occurs after 30 years of age and is commonly treated as
type 2 diabetes.
June 14, 2019
Thomas NJ, Lynam AL, Hill A, et al. Type 1 diabetes defined by severe insulin deficiency occurs after
30 years of age and is commonly treated as type 2 diabetes. Diabetologia.…
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psnet.ahrq.gov/node/838245/psn-pdf
January 01, 2023 - A novel study of situational awareness among out-of-
hospital providers during an online clinical simulation.
October 5, 2022
Hunter J, Porter M, Williams B. A novel study of situational awareness among out-of-hospital providers
during an online clinical simulation. Australas Emerg Care. 2023;26(1):96-103.
doi:10.…
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psnet.ahrq.gov/node/836807/psn-pdf
March 30, 2022 - Preventing delayed and missed care by applying artificial
intelligence to trigger radiology imaging follow-up.
March 30, 2022
Domingo J, Galal G, Huang J. Preventing delayed and missed care by applying artificial intelligence to
trigger radiology imaging follow-up. NEJM Catal Innov Care Deliv. 2022;3(4).
https://p…
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psnet.ahrq.gov/node/47896/psn-pdf
July 10, 2019 - Engaging patients and informal caregivers to improve
safety and facilitate person- and family-centered care
during transitions from hospital to home: a qualitative
descriptive study.
July 10, 2019
Backman C, Cho-Young D. Engaging patients and informal caregivers to improve safety and facilitate
person- and family…
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psnet.ahrq.gov/node/47370/psn-pdf
October 10, 2018 - Development of a conceptual map of negative
consequences for patients of overuse of medical tests
and treatments.
October 10, 2018
Korenstein D, Chimonas S, Barrow B, et al. Development of a Conceptual Map of Negative Consequences
for Patients of Overuse of Medical Tests and Treatments. JAMA Intern Med. 2018;178(1…
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psnet.ahrq.gov/node/862989/psn-pdf
February 21, 2024 - Peer support and second victim programs for anesthesia
professionals involved in stressful or traumatic clinical
events.
February 21, 2024
Finney RE, Jacob AK. Peer support and second victim programs for anesthesia professionals involved in
stressful or traumatic clinical events. Adv Anesth. 2023;41(1):39-52. doi:…
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psnet.ahrq.gov/node/43481/psn-pdf
December 23, 2016 - Managing risk during transition to new ISO tubing
connector standards.
December 23, 2016
Sentinel Event Alert. August 20, 2014;(53):1-6.
https://psnet.ahrq.gov/issue/managing-risk-during-transition-new-iso-tubing-connector-standards
The Joint Commission issues sentinel event alerts in response to significant emerg…
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psnet.ahrq.gov/node/857452/psn-pdf
December 06, 2023 - Improving patient safety governance and systems
through learning from successes and failures: qualitative
surveys and interviews with international experts.
December 6, 2023
Hibbert PD, Stewart S, Wiles LK, et al. Improving patient safety governance and systems through learning
from successes and failures: qualita…
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psnet.ahrq.gov/node/34063/psn-pdf
September 18, 2011 - Risk factors for retained instruments and sponges after
surgery.
September 18, 2011
Gawande AA, Studdert DM, Orav J, et al. Risk factors for retained instruments and sponges after surgery.
N Engl J Med. 2003;348(3):229-35.
https://psnet.ahrq.gov/issue/risk-factors-retained-instruments-and-sponges-after-surgery
Th…
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psnet.ahrq.gov/node/851448/psn-pdf
July 19, 2023 - Medication reconciliation for patients after their discharge
from intensive care unit to the hospital ward.
July 19, 2023
Pradeda AM, Pérez MSA, Oliveira CF, et al. Medication reconciliation for patients after their discharge from
intensive care unit to the hospital ward. Farm Hosp. 2023;47(3):121-126. doi:10.1016/…
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psnet.ahrq.gov/node/847535/psn-pdf
April 12, 2023 - Using the Generic Analysis Method to analyze sentinel
event reports across hospitals: a retrospective cross-
sectional study.
April 12, 2023
Baartmans MC, van Schoten SM, Smit BJ, et al. Using the Generic Analysis Method to analyze sentinel
event reports across hospitals: a retrospective cross-sectional study. J P…
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psnet.ahrq.gov/node/44669/psn-pdf
January 22, 2016 - Safety standards: implementing fall prevention
interventions and sustaining lower fall rates by promoting
the culture of safety on an inpatient rehabilitation unit.
January 22, 2016
Leone RM, Adams RJ. Safety Standards: Implementing Fall Prevention Interventions and Sustaining Lower
Fall Rates by Promoting the Cul…
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psnet.ahrq.gov/node/844765/psn-pdf
September 18, 2019 - Untangling infusion confusion: a comparative evaluation
of interventions in a simulated intensive care setting.
September 18, 2019
Pinkney SJ, Fan M, Koczmara C, et al. Untangling Infusion Confusion: A Comparative Evaluation of
Interventions in a Simulated Intensive Care Setting. Crit Care Med. 2019;47(7):e597-e601…
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psnet.ahrq.gov/node/837764/psn-pdf
August 03, 2022 - Disparities in adverse event reporting for hospitalized
children.
August 3, 2022
Halvorson EE, Thurtle DP, Easter A, et al. Disparities in adverse event reporting for hospitalized children. J
Patient Saf. 2022;18(6):e928-e933. doi:10.1097/pts.0000000000001049.
https://psnet.ahrq.gov/issue/disparities-adverse-event…