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psnet.ahrq.gov/node/60518/psn-pdf
May 27, 2020 - Infection Control Deficiencies Were Widespread and
Persistent in Nursing Homes Prior to COVID-19 Pandemic.
May 27, 2020
Washington, DC: United States Government Accountability Office; May 20, 2020. Publication GAO-20-
576R.
https://psnet.ahrq.gov/issue/infection-control-deficiencies-were-widespre…
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psnet.ahrq.gov/node/36644/psn-pdf
July 10, 2008 - Reporting and disclosing medical errors: pediatricians'
attitudes and behaviors.
July 10, 2008
Garbutt J, Brownstein DR, Klein EJ, et al. Reporting and disclosing medical errors: pediatricians' attitudes
and behaviors. Arch Pediatr Adolesc Med. 2007;161(2):179-85.
https://psnet.ahrq.gov/issue/reporting-and-disclos…
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psnet.ahrq.gov/node/37047/psn-pdf
September 30, 2011 - Briefing and debriefing in the operating room using
fighter pilot crew resource management.
September 30, 2011
McGreevy JM, Otten TD. Briefing and debriefing in the operating room using fighter pilot crew resource
management. J Am Coll Surg. 2007;205(1):169-76.
https://psnet.ahrq.gov/issue/briefing-and-debriefing-…
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psnet.ahrq.gov/node/837742/psn-pdf
July 27, 2022 - Room of hazards: a comparison of differences in safety
hazard recognition among various hospital-based
healthcare professionals and trainees in a simulated
patient room.
July 27, 2022
Wang M, Banda B, Rodwin BA, et al. Room of hazards: a comparison of differences in safety hazard
recognition among various hospita…
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psnet.ahrq.gov/node/837700/psn-pdf
July 20, 2022 - Temporal associations between EHR-derived workload,
burnout, and errors: a prospective cohort study.
July 20, 2022
Lou SS, Lew D, Harford DR, et al. Temporal associations between EHR-derived workload, burnout, and
errors: a prospective cohort study. J Gen Intern Med. 2022;37(9):2165-2172. doi:10.1007/s11606-022-
0…
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psnet.ahrq.gov/node/837148/psn-pdf
May 18, 2022 - Assessing quality of older persons' emergency
transitions between long-term and acute care settings: a
proof-of-concept study.
May 18, 2022
Tate K, McLane P, Reid C, et al. Assessing quality of older persons’ emergency transitions between long-
term and acute care settings: a proof-of-concept study. BMJ Open Qual.…
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psnet.ahrq.gov/node/74172/psn-pdf
December 08, 2021 - Differences in safety report event types submitted by
graduate medical education trainees compared with other
healthcare team members.
December 8, 2021
Cohen SP, McLean HS, Milne J, et al. Differences in Safety Report Event Types Submitted by Graduate
Medical Education Trainees Compared With Other Healthcare Team …
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psnet.ahrq.gov/node/44228/psn-pdf
September 04, 2016 - Bridging the gap: a framework and strategies for
integrating the quality and safety mission of teaching
hospitals and graduate medical education.
September 4, 2016
Tess A, Vidyarthi A, Yang J, et al. Bridging the Gap: A Framework and Strategies for Integrating the Quality
and Safety Mission of Teaching Hospitals a…
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psnet.ahrq.gov/node/846751/psn-pdf
March 29, 2023 - High-fidelity simulation’s impact on clinical reasoning and
patient safety: a scoping review.
March 29, 2023
El Hussein MT, Hirst SP. High-fidelity simulation’s impact on clinical reasoning and patient safety: a
scoping review. J Nurs Reg. 2023;13(4):54-65. doi:10.1016/s2155-8256(23)00028-5.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/72710/psn-pdf
February 03, 2021 - A poison information centre can provide important
assessment and guidance regarding medication errors in
nursing homes: a prospective cohort study.
February 3, 2021
Vinther S, Bøgevig S, Eriksen KR, et al. A poison information centre can provide important assessment and
guidance regarding medication errors in nurs…
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psnet.ahrq.gov/node/74862/psn-pdf
February 23, 2022 - Use of pediatric injectable medicines guidelines and
associated medication administration errors: a human
reliability analysis.
February 23, 2022
Jones MD, Clarke J, Feather C, et al. Use of pediatric injectable medicines guidelines and associated
medication administration errors: a human reliability analysis. Ann…
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psnet.ahrq.gov/node/841761/psn-pdf
December 21, 2022 - Are the World Health Organization's patient safety
learning objectives still up-to-date: a group concept
mapping study.
December 21, 2022
Vogt L, Stoyanov S, Bergs J, et al. Are the World Health Organization's patient safety learning objectives
still up-to-date: a group concept mapping study. J Patient Saf. 2022;1…
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psnet.ahrq.gov/node/764403/psn-pdf
March 02, 2022 - Radiologist errors by modality, anatomic region, and
pathology for 1.6 million exams: what we have learned.
March 2, 2022
Lamoureux C, Hanna TN, Sprecher D, et al. Radiologist errors by modality, anatomic region, and pathology
for 1.6 million exams: what we have learned. Emerg Radiol. 2021;28(6):1135-1141. doi:10.1…
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psnet.ahrq.gov/node/73187/psn-pdf
April 28, 2021 - Improving handoff by deliberate cognitive processing:
results from a randomized controlled experimental study.
April 28, 2021
van Heesch G, Frenkel J, Kollen W, et al. Improving handoff by deliberate cognitive processing: results
from a randomized controlled experimental study. Jt Comm J Qual Patient Saf. 2020;47(4…
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psnet.ahrq.gov/node/60536/psn-pdf
May 27, 2020 - Nursing home workers warned government about safety
violations before COVID-19 outbreaks and deaths.
May 27, 2020
Ellis B, Hicken M. CNN. May 14, 2020.
https://psnet.ahrq.gov/issue/nursing-home-workers-warned-government-about-safety-violations-covid-19-
outbreaks-and-deaths
Long-term care and skilled nursing faci…
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psnet.ahrq.gov/node/45389/psn-pdf
September 27, 2016 - Prevalence of potentially inappropriate medication use in
older adults living in nursing homes: a systematic review.
September 27, 2016
Morin L, Laroche M-L, Texier G, et al. Prevalence of potentially inappropriate medication use in older adults
living in nursing homes: a systematic review. J Am Med Dir Assoc. 2016…
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psnet.ahrq.gov/node/46017/psn-pdf
July 11, 2017 - Challenging hierarchy in healthcare teams--ways to
flatten gradients to improve teamwork and patient care.
July 11, 2017
Green B, Oeppen RS, Smith DW, et al. Challenging hierarchy in healthcare teams - ways to flatten
gradients to improve teamwork and patient care. Br J Oral Maxillofac Surg. 2017;55(5):449-453.
do…
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psnet.ahrq.gov/node/35403/psn-pdf
February 18, 2011 - Mortality among patients admitted to hospitals on
weekends as compared with weekdays.
February 18, 2011
Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with
weekdays. New Engl J Med. 2001;345(9):663-668.
https://psnet.ahrq.gov/issue/mortality-among-patients-admitted-h…
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psnet.ahrq.gov/node/867222/psn-pdf
December 04, 2024 - How many is too many? Using cognitive load theory to
determine the maximum safe number of inpatient
consultations for trainees.
December 4, 2024
Brondfield S, Blum AM, Mason JM, et al. How many is too many? Using cognitive load theory to determine
the maximum safe number of inpatient consultations for trainees. Ac…
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psnet.ahrq.gov/node/848038/psn-pdf
April 26, 2023 - Assessing system thinking in senior pharmacy students
using the innovative "Horror Room" simulation setting: a
cross-sectional survey of a non-technical skill.
April 26, 2023
Aljuffali LA, Almalag HM, Alnaim L. Assessing system thinking in senior pharmacy students using the
innovative "Horror Room" simulation sett…