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psnet.ahrq.gov/node/38941/psn-pdf
November 25, 2009 - Nurse-physician communication in the long-term care
setting: perceived barriers and impact on patient safety.
November 25, 2009
Tjia J, Mazor KM, Field T, et al. Nurse-physician communication in the long-term care setting: perceived
barriers and impact on patient safety. J Patient Saf. 2009;5(3):145-152.
doi:10.10…
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psnet.ahrq.gov/node/43280/psn-pdf
November 30, 2016 - Medical Office Survey on Patient Safety Culture: 2014
User Comparative Database Report.
November 30, 2016
Sorra J, Famolaro T, Yount ND, et al. Rockville, MD: Agency for Healthcare Research and Quality; June
2014. Report No. 14-0032-EF.
https://psnet.ahrq.gov/issue/medical-office-survey-patient-safety-culture-2014…
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psnet.ahrq.gov/node/45116/psn-pdf
February 15, 2017 - Postoperative adverse events inconsistently improved by
the World Health Organization surgical safety checklist: a
systematic literature review of 25 studies.
February 15, 2017
de Jager E, McKenna C, Bartlett L, et al. Postoperative adverse events inconsistently improved by the
World Health Organization surgical s…
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psnet.ahrq.gov/node/40048/psn-pdf
December 01, 2010 - Temporal trends in rates of patient harm resulting from
medical care.
December 1, 2010
Landrigan CP, Parry G, Bones CB, et al. Temporal trends in rates of patient harm resulting from medical
care. N Engl J Med. 2010;363(22):2124-34. doi:10.1056/NEJMsa1004404.
https://psnet.ahrq.gov/issue/temporal-trends-rates-pati…
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psnet.ahrq.gov/node/38411/psn-pdf
December 16, 2014 - A reengineered hospital discharge program to decrease
rehospitalization: a randomized trial.
December 16, 2014
Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease
rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-87.
https://psnet.ahrq.gov/issue/reengine…
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psnet.ahrq.gov/node/39457/psn-pdf
April 12, 2011 - Disclosure of medical error to parents and paediatric
patients: assessment of parents' attitudes and influencing
factors.
April 12, 2011
Matlow AG, Moody L, Laxer R, et al. Disclosure of medical error to parents and paediatric patients:
assessment of parents' attitudes and influencing factors. Arch Dis Child. 2009…
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psnet.ahrq.gov/node/41455/psn-pdf
June 13, 2012 - Medication errors during medical emergencies in a large,
tertiary care, academic medical center.
June 13, 2012
Gokhman R, Seybert AL, Phrampus P, et al. Medication errors during medical emergencies in a large,
tertiary care, academic medical center. Resuscitation. 2012;83(4):482-7.
doi:10.1016/j.resuscitation.2011…
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psnet.ahrq.gov/node/47152/psn-pdf
October 12, 2018 - A quality initiative: a system-wide reduction in serious
medication events through targeted simulation training.
October 12, 2018
Hebbar KB, Colman N, Williams L, et al. A Quality Initiative: A System-Wide Reduction in Serious
Medication Events Through Targeted Simulation Training. Simul Healthc. 2018;13(5):324-330…
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psnet.ahrq.gov/node/42693/psn-pdf
December 23, 2016 - Preventing unintended retained foreign objects.
December 23, 2016
Preventing unintended retained foreign objects. Sentinel event alert. 2013;(51):1-5.
https://psnet.ahrq.gov/issue/preventing-unintended-retained-foreign-objects
Sentinel event alerts are issued periodically by The Joint Commission to identify common …
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psnet.ahrq.gov/node/46323/psn-pdf
October 29, 2017 - Use of unit-based interventions to improve the quality of
care for hospitalized medical patients: a national survey.
October 29, 2017
O'Leary KJ, Johnson J, Manojlovich M, et al. Use of Unit-Based Interventions to Improve the Quality of
Care for Hospitalized Medical Patients: A National Survey. Jt Comm J Qual Patie…
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psnet.ahrq.gov/node/39583/psn-pdf
October 30, 2010 - The harm susceptibility model: a method to prioritise
risks identified in patient safety reporting systems.
October 30, 2010
Pham JC, Colantuoni E, Dominici F, et al. The harm susceptibility model: a method to prioritise risks
identified in patient safety reporting systems. Qual Saf Health Care. 2010;19(5):440-5.
…
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psnet.ahrq.gov/node/40726/psn-pdf
July 03, 2014 - Automated identification of postoperative complications
within an electronic medical record using natural
language processing.
July 3, 2014
Murff HJ, FitzHenry F, Matheny ME, et al. Automated identification of postoperative complications within an
electronic medical record using natural language processing. JAMA. …
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psnet.ahrq.gov/node/46986/psn-pdf
June 27, 2018 - A multi-hospital before–after observational study using a
point-prevalence approach with an infusion safety
intervention bundle to reduce intravenous medication
administration errors.
June 27, 2018
Schnock KO, Dykes PC, Albert J, et al. A Multi-hospital Before-After Observational Study Using a Point-
Prevalence A…
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psnet.ahrq.gov/node/38076/psn-pdf
February 15, 2011 - Consequences of inadequate sign-out for patient care.
February 15, 2011
Horwitz LI, Moin T, Krumholz HM, et al. Consequences of inadequate sign-out for patient care. Arch Intern
Med. 2008;168(16):1755-60. doi:10.1001/archinte.168.16.1755.
https://psnet.ahrq.gov/issue/consequences-inadequate-sign-out-patient-care
W…
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psnet.ahrq.gov/node/43617/psn-pdf
September 24, 2016 - Do telephone call interruptions have an impact on
radiology resident diagnostic accuracy?
September 24, 2016
Balint BJ, Steenburg SD, Lin H, et al. Do telephone call interruptions have an impact on radiology resident
diagnostic accuracy? Acad Radiol. 2014;21(12):1623-8. doi:10.1016/j.acra.2014.08.001.
https://psne…
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psnet.ahrq.gov/node/43341/psn-pdf
July 23, 2014 - Effectiveness of different nursing handover styles for
ensuring continuity of information in hospitalised
patients.
July 23, 2014
Smeulers M, Lucas C, Vermeulen H. Effectiveness of different nursing handover styles for ensuring
continuity of information in hospitalised patients. Cochrane Database of Syst Rev. 2014…
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psnet.ahrq.gov/issue/10-medication-safety-tips-hospitalized-patients
February 06, 2019 - June 13, 2018
Severe hyperglycemia in patients incorrectly using insulin pens at home
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psnet.ahrq.gov/issue/ismp-long-term-care-advise-err
June 07, 2017 - June 13, 2018
Severe hyperglycemia in patients incorrectly using insulin pens at home
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psnet.ahrq.gov/issue/clinical-issues-series
July 05, 2006 - 2006
National Partnership for Maternal Safety: consensus bundle on support after a severe
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psnet.ahrq.gov/issue/fatal-gas-line-mix-how-avoid-making-gastly-mistake
April 29, 2018 - September 12, 2016
ALERT: reports of severe harm after intravenous administration of