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psnet.ahrq.gov/node/47978/psn-pdf
May 01, 2019 - Patient Safety.
May 1, 2019
GMS J Med Educ. 2019;36:Doc11-Doc22.
https://psnet.ahrq.gov/issue/patient-safety-16
Patient safety has been described as an unmet need in physician training. This special issue covers areas
of focus for a patient safety curriculum drawn from experience in the German medical education sy…
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psnet.ahrq.gov/node/44139/psn-pdf
June 10, 2015 - In situ simulated cardiac arrest exercises to detect
system vulnerabilities.
June 10, 2015
Barbeito A, Bonifacio AS, Holtschneider M, et al. In situ simulated cardiac arrest exercises to detect system
vulnerabilities. Simul Healthc. 2015;10(3):154-62. doi:10.1097/SIH.0000000000000087.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/42782/psn-pdf
January 19, 2014 - Developing a medical emergency team running sheet to
improve clinical handoff and documentation.
January 19, 2014
Mardegan K, Heland M, Whitelock T, et al. Developing a medical emergency team running sheet to
improve clinical handoff and documentation. Jt Comm J Qual Patient Saf. 2013;39(12):570-575.
https://psnet…
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psnet.ahrq.gov/node/73996/psn-pdf
October 29, 2021 - Patient, Medical, and Legal Perspectives of Unsafe Care.
October 20, 2021
Patient Safety Movement. October 29, 2021.
https://psnet.ahrq.gov/issue/patient-medical-and-legal-perspectives-unsafe-care
Effective response to medical harm involves a variety of perspectives that are aligned in purpose. This
webinar …
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psnet.ahrq.gov/node/836934/psn-pdf
March 12, 2025 - Top 10 Patient Safety Concerns.
March 12, 2025
Plymouth Meeting, PA: ECRI; March 2025.
https://psnet.ahrq.gov/issue/top-10-patient-safety-concerns
This annual consensus report identifies actions harboring risks that contribute to preventable patient harm.
The top ten concerns for 2025 include poor response to…
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psnet.ahrq.gov/node/35339/psn-pdf
April 23, 2014 - Disclosing harmful medical errors to patients: a time for
professional action.
April 23, 2014
Gallagher TH, Levinson W. Disclosing Harmful Medical Errors to Patients. Arch Intern Med. 2005;165(16).
doi:10.1001/archinte.165.16.1819.
https://psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients-time-profes…
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psnet.ahrq.gov/node/39586/psn-pdf
January 09, 2011 - Relationship between systems-level factors and hand
hygiene adherence.
January 9, 2011
Dunn-Navarra A-M, Cohen B, Stone PW, et al. Relationship between systems-level factors and hand
hygiene adherence. J Nurs Care Qual. 2011;26(1):30-38. doi:10.1097/NCQ.0b013e3181e15c71.
https://psnet.ahrq.gov/issue/relationship-b…
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psnet.ahrq.gov/node/43659/psn-pdf
November 05, 2014 - Intraoperative patient information handover between
anesthesia providers.
November 5, 2014
Choromanski D, Frederick J, McKelvey GM, et al. Intraoperative patient information handover between
anesthesia providers. J Biomed Res. 2014;28(5):383-387. doi:10.7555/JBR.28.20140001.
https://psnet.ahrq.gov/issue/intraopera…
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psnet.ahrq.gov/node/46272/psn-pdf
January 01, 2019 - Deployment of a second victim peer support program: a
replication study.
September 24, 2017
Merandi J, Liao NN, Lewe D, et al. Deployment of a second victim peer support program: a replication
study. Pediatr Qual Saf. 2019;2(4):e031. doi:10.1097/pq9.0000000000000031.
https://psnet.ahrq.gov/issue/deployment-second-…
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psnet.ahrq.gov/node/50835/psn-pdf
January 29, 2020 - Safe work-hour standards for parents of children with
medical complexity.
January 29, 2020
Schall TE, Foster CC, Feudtner C. Safe Work-Hour Standards for Parents of Children With Medical
Complexity. JAMA Pediatr. 2019;174(1):7-8. doi:10.1001/jamapediatrics.2019.4003.
https://psnet.ahrq.gov/issue/safe-work-hour-sta…
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psnet.ahrq.gov/node/34922/psn-pdf
February 25, 2009 - Potential errors and their prevention in operating room
teamwork as experienced by Finnish, British and
American nurses.
February 25, 2009
Silén-Lipponen M, Tossavainen K, Turunen H, et al. Potential errors and their prevention in operating room
teamwork as experienced by Finnish, British and American nurses. Int …
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psnet.ahrq.gov/node/36576/psn-pdf
January 14, 2011 - Need for standardized sign-out in the emergency
department: a survey of emergency medicine residency
and pediatric emergency medicine fellowship program
directors.
January 14, 2011
Sinha M, Shriki J, Salness R, et al. Need for standardized sign-out in the emergency department: a survey
of emergency medicine resid…
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psnet.ahrq.gov/node/847731/psn-pdf
April 19, 2023 - Lessons from health care leaders: rethinking and
reinvesting in patient safety.
April 19, 2023
doi:10.1056/CAT.23.0090.
https://psnet.ahrq.gov/issue/lessons-health-care-leaders-rethinking-and-reinvesting-patient-safety
Progress in patient safety has been disappointingly slow. This commentary shares thoughts from a…
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psnet.ahrq.gov/node/44192/psn-pdf
November 10, 2015 - Hospital ratings: a guide for the perplexed.
November 10, 2015
Zuger A. Hospital ratings: a guide for the perplexed. JAMA. 2015;313(19):1911-2.
doi:10.1001/jama.2015.5269.
https://psnet.ahrq.gov/issue/hospital-ratings-guide-perplexed
Concerns have been raised about the variability of measures used to rate safety a…
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psnet.ahrq.gov/node/43269/psn-pdf
July 28, 2014 - Restoring trust in VA health care.
July 28, 2014
Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med. 2014;371(4):295-297.
doi:10.1056/NEJMp1406852.
https://psnet.ahrq.gov/issue/restoring-trust-va-health-care
In response to a recent investigation raising concerns about inaccurate reporting of wait-ti…
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psnet.ahrq.gov/node/41453/psn-pdf
November 26, 2014 - Judging whether a patient is actually improving: more
pitfalls from the science of human perception.
November 26, 2014
Redelmeier DA, Dickinson VM. Judging whether a patient is actually improving: more pitfalls from the
science of human perception. J Gen Intern Med. 2012;27(9):1195-9. doi:10.1007/s11606-012-2097-2.…
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psnet.ahrq.gov/node/60585/psn-pdf
June 10, 2020 - Pandemic presents new hurdles, and hope, for people
struggling with addiction.
June 10, 2020
Feldman N. Kaiser Health News. June 2, 2020.
https://psnet.ahrq.gov/issue/pandemic-presents-new-hurdles-and-hope-people-struggling-addiction
Physical distancing as a COVID-19 prevention strategy has had a range of unintend…
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psnet.ahrq.gov/node/847550/psn-pdf
April 12, 2023 - What's changed 1 year after RaDonda Vaught's
conviction?
April 12, 2023
Bean M, Carbajal E. Becker's Hospital Review. March 29, 2023.
https://psnet.ahrq.gov/issue/whats-changed-1-year-after-radonda-vaughts-conviction
The RaDonda Vaught conviction reverberated throughout health care and marked weaknesses in systems…
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psnet.ahrq.gov/node/60531/psn-pdf
May 27, 2020 - Telenursing in incidents and disasters: a systematic
review of the literature.
May 27, 2020
Nejadshafiee M, Bahaadinbeigy K, Kazemi M, et al. Telenursing in incidents and disasters: a systematic
review of the literature. J Emerg Nurs. 2020. doi:10.1016/j.jen.2020.03.005.
https://psnet.ahrq.gov/issue/telenursing-in…
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psnet.ahrq.gov/node/40294/psn-pdf
September 24, 2016 - Hospital doctors' workflow interruptions and activities: an
observation study.
September 24, 2016
Weigl M, Müller A, Zupanc A, et al. Hospital doctors' workflow interruptions and activities: an observation
study. BMJ Qual Saf. 2011;20(6):491-7. doi:10.1136/bmjqs.2010.043281.
https://psnet.ahrq.gov/issue/hospital-d…