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psnet.ahrq.gov/node/60300/psn-pdf
May 06, 2020 - The coronavirus and the risks to the elderly in long-term
care.
May 6, 2020
Gardner W, States D, Bagley N. The coronavirus and the risks to the elderly in long-term care. J Aging Soc
Policy. 2020;32(4-5):310-315. doi:10.1080/08959420.2020.1750543.
https://psnet.ahrq.gov/issue/coronavirus-and-risks-elderly-long-ter…
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psnet.ahrq.gov/node/73479/psn-pdf
July 07, 2021 - Mitigating the July effect.
July 7, 2021
Wu AW, Vincent CA, Shapiro DW, et al. Mitigating the July effect. J Patient Saf Risk Manag.
2021;26(3):93-96. doi:10.1177/25160435211019142.
https://psnet.ahrq.gov/issue/mitigating-july-effect
The July effect is a phenomenon that presumably results in poor care due to the a…
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psnet.ahrq.gov/node/45155/psn-pdf
May 25, 2016 - Interdisciplinary ICU cardiac arrest debriefing improves
survival outcomes.
May 25, 2016
Wolfe H, Zebuhr C, Topjian AA, et al. Interdisciplinary ICU cardiac arrest debriefing improves survival
outcomes*. Crit Care Med. 2014;42(7):1688-95. doi:10.1097/CCM.0000000000000327.
https://psnet.ahrq.gov/issue/interdiscipli…
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psnet.ahrq.gov/node/73502/psn-pdf
July 14, 2021 - Toolkit to Improve Antibiotic Use in Long-Term Care.
July 14, 2021
Rockville, MD: Agency for Healthcare Research and Quality; June 2021.
https://psnet.ahrq.gov/issue/toolkit-improve-antibiotic-use-long-term-care
The use of antibiotics should be monitored to reduce the potential for infection in care facilities. Thi…
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psnet.ahrq.gov/node/844054/psn-pdf
March 12, 2025 - Lewis Blackman Patient Safety Award.
December 17, 2024
Chicago, IL: American College of Graduate Medical Education.
https://psnet.ahrq.gov/issue/lewis-blackman-patient-safety-award
Lewis Blackman was a young man who lost his life to medical error when the severity of his condition after
elective surgery was unreco…
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psnet.ahrq.gov/node/41722/psn-pdf
October 17, 2012 - Remaking surgical socialization: work hour restrictions,
rites of passage, and occupational identity.
October 17, 2012
Veazey Brooks J, Bosk CL. Remaking surgical socialization: Work hour restrictions, rites of passage, and
occupational identity. Soc Sci Med. 2012;75(9). doi:10.1016/j.socscimed.2012.07.007.
https:…
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psnet.ahrq.gov/node/35054/psn-pdf
February 24, 2011 - Do physicians know when their diagnoses are correct?
Implications for decision support and error reduction.
February 24, 2011
Friedman CP, Gatti GG, Franz TM, et al. Do physicians know when their diagnoses are correct?
Implications for decision support and error reduction. J Gen Intern Med. 2005;20(4):334-9.
https…
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psnet.ahrq.gov/node/39323/psn-pdf
February 24, 2010 - Measuring communication in the surgical ICU: better
communication equals better care.
February 24, 2010
Williams M, Hevelone N, Alban RF, et al. Measuring communication in the surgical ICU: better
communication equals better care. J Am Coll Surg. 2010;210(1):17-22.
doi:10.1016/j.jamcollsurg.2009.09.025.
https://p…
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psnet.ahrq.gov/node/34884/psn-pdf
August 03, 2009 - Communication failures: an insidious contributor to
medical mishaps.
August 3, 2009
Sutcliffe K, Lewton E, Rosenthal M. Communication failures: an insidious contributor to medical mishaps.
Acad Med. 2004;79(2):186-194.
https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps
In or…
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psnet.ahrq.gov/node/47435/psn-pdf
November 07, 2018 - Cognitive bias in clinical medicine.
November 7, 2018
O'Sullivan ED, Schofield SJ. Cognitive bias in clinical medicine. J R Coll Physicians Edinb. 2018;48(3):225-
232. doi:10.4997/JRCPE.2018.306.
https://psnet.ahrq.gov/issue/cognitive-bias-clinical-medicine
Cognitive biases can lead to unnecessary treatment and de…
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psnet.ahrq.gov/node/40542/psn-pdf
August 25, 2011 - Optimising surgical training: use of feedback to reduce
errors during a simulated surgical procedure.
August 25, 2011
Boyle E, Al-Akash M, Gallagher AG, et al. Optimising surgical training: use of feedback to reduce errors
during a simulated surgical procedure. Postgrad Med J. 2011;87(1030):524-8.
doi:10.1136/pgmj…
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psnet.ahrq.gov/node/38460/psn-pdf
February 16, 2011 - Intern to attending: assessing stress among physicians.
February 16, 2011
Stucky E, Dresselhaus TR, Dollarhide A, et al. Intern to attending: assessing stress among physicians.
Acad Med. 2009;84(2):251-7. doi:10.1097/ACM.0b013e3181938aad.
https://psnet.ahrq.gov/issue/intern-attending-assessing-stress-among-physicia…
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psnet.ahrq.gov/node/41549/psn-pdf
September 24, 2016 - Realistic distractions and interruptions that impair
simulated surgical performance by novice surgeons.
September 24, 2016
Feuerbacher RL, Funk KH, Spight DH, et al. Realistic distractions and interruptions that impair simulated
surgical performance by novice surgeons. Arch Surg. 2012;147(11):1026-1030.
doi:10.100…
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psnet.ahrq.gov/node/40487/psn-pdf
June 01, 2011 - Developing and testing a tool to measure nurse/physician
communication in the intensive care unit.
June 1, 2011
Carbo AR, Tess AV, Roy CL, et al. Developing a High-Performance Team Training Framework for Internal
Medicine Residents. J Patient Saf. 2011;7(2). doi:10.1097/pts.0b013e31820dbe02.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/45450/psn-pdf
February 13, 2018 - Avoiding Unconscious Bias: a Guide for Surgeons.
February 13, 2018
London, UK: Royal College of Surgeons of England; 2016.
https://psnet.ahrq.gov/issue/avoiding-unconscious-bias-guide-surgeons
Biases can affect decision making and behaviors toward colleagues and patients. This guidance provides
information for sur…
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psnet.ahrq.gov/node/40821/psn-pdf
October 31, 2011 - Educational interventions to improve handover in health
care: a systematic review.
October 31, 2011
Gordon M, Findley R. Educational interventions to improve handover in health care: a systematic review.
Med Educ. 2011;45(11):1081-9. doi:10.1111/j.1365-2923.2011.04049.x.
https://psnet.ahrq.gov/issue/educational-in…
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psnet.ahrq.gov/node/34739/psn-pdf
February 06, 2018 - Complications: A Surgeon's Notes on an Imperfect
Science.
February 6, 2018
Gawande A. New York, NY: Metropolitan Books; 2002. ISBN: 9780805063196.
https://psnet.ahrq.gov/issue/complications-surgeons-notes-imperfect-science
In Complications, Gawande reprises and builds on a series of feature articles, several writt…
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psnet.ahrq.gov/node/41102/psn-pdf
February 01, 2012 - Medication administration errors for older people in long-
term residential care.
February 1, 2012
Szczepura A, Wild D, Nelson S. Medication administration errors for older people in long-term residential
care. BMC Geriatr. 2011;11:82. doi:10.1186/1471-2318-11-82.
https://psnet.ahrq.gov/issue/medication-administra…
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psnet.ahrq.gov/node/46332/psn-pdf
September 24, 2017 - Sharing the process of diagnostic decision making.
September 24, 2017
Brush JE, Brophy JM. Sharing the Process of Diagnostic Decision Making. JAMA Intern Med.
2017;177(9):1245-1246. doi:10.1001/jamainternmed.2017.1929.
https://psnet.ahrq.gov/issue/sharing-process-diagnostic-decision-making
Improving diagnosis has …
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psnet.ahrq.gov/node/44452/psn-pdf
September 04, 2016 - Reflecting on diagnostic errors: taking a second look is
not enough.
September 4, 2016
Monteiro SD, Sherbino J, Patel A, et al. Reflecting on Diagnostic Errors: Taking a Second Look is Not
Enough. J Gen Intern Med. 2015;30(9):1270-4. doi:10.1007/s11606-015-3369-4.
https://psnet.ahrq.gov/issue/reflecting-diagnostic…