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  1. Improving the bar-coded medication administration system at the Department of Veterans Affairs. | PSNet

    psnet.ahrq.gov/issue/improving-bar-coded-medication-administration-system-department-veterans-affairs
    November 18, 2009 - Study Improving the bar-coded medication administration system at the Department of Veterans Affairs. Citation Text: Mills PD, Neily J, Mims E, et al. Improving the bar-coded medication administration system at the Department of Veterans Affairs. Am J Health Syst Pharm. 2006;63(15):144…

  2. Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit. | PSNet

    psnet.ahrq.gov/issue/use-design-thinking-and-human-factors-approach-improve-situation-awareness-pediatric
    January 19, 2022 - Study Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit. Citation Text: Gifford A, Butcher B, Chima RS, et al. Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive c…

  3. Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis. | PSNet

    psnet.ahrq.gov/issue/shared-understanding-resilient-practices-context-inpatient-suicide-prevention-narrative
    December 23, 2020 - Study Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis. Citation Text: Berg SH, Rørtveit K, Walby FA, et al. Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis.…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46719/psn-pdf
    December 20, 2017 - Frustrated with your EHR? Don't blame your vendor—safety is a shared responsibility. December 20, 2017 Singh H, Sittig DF. NEJM Catalyst. December 7, 2017. https://psnet.ahrq.gov/issue/frustrated-your-ehr-dont-blame-your-vendor-safety-shared-responsibility The promise of health information technology has yet to be…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854988/psn-pdf
    November 01, 2023 - Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit. November 1, 2023 Gifford A, Butcher B, Chima RS, et al. Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit. J Hosp Med. 2023;18(1…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42897/psn-pdf
    March 12, 2017 - Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare. March 12, 2017 Weller J, Boyd M, Cumin D. Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare. Postgrad Med J. 2014;90(1061):149-54. doi:10.1136/postgradmedj-2012-131168. https://psnet.a…

  7. Using clinical decision support to improve medication reconciliation. | PSNet

    psnet.ahrq.gov/issue/using-clinical-decision-support-improve-medication-reconciliation
    December 10, 2014 - Newspaper/Magazine Article Using clinical decision support to improve medication reconciliation. Citation Text: Using clinical decision support to improve medication reconciliation. Moore G. Patient Saf Qual Healthc. November / December 2006. Copy Citation Save …

  8. When a heart attack goes undiagnosed. | PSNet

    psnet.ahrq.gov/issue/when-heart-attack-goes-undiagnosed
    November 08, 2023 - Newspaper/Magazine Article When a heart attack goes undiagnosed. Citation Text: When a heart attack goes undiagnosed. Davis R. USA Today. Oct 2006. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter …

  9. How implicit bias harms patient care. | PSNet

    psnet.ahrq.gov/issue/how-implicit-bias-harm-patient-care
    December 04, 2019 - Newspaper/Magazine Article How implicit bias harms patient care. Citation Text: How implicit bias harms patient care. Bendix J. Med Econ. November 25, 2019;96(23);10-14. Copy Citation Save Save to your library Print Download PDF Share Faceb…

  10. Better care for surgical patients: recognizing and responding to the unexpected to save lives. | PSNet

    psnet.ahrq.gov/issue/better-care-surgical-patients-recognizing-and-responding-unexpected-save-lives
    January 11, 2017 - Image/Poster Better care for surgical patients: recognizing and responding to the unexpected to save lives. Citation Text: Better care for surgical patients: recognizing and responding to the unexpected to save lives. Ghaferi A. IHPI Brief. December 2019.         &n…

  11. 'I think this medicine actually killed my wife': patient and family perspectives on shared decision-making to optimize medications and safety. | PSNet

    psnet.ahrq.gov/issue/i-think-medicine-actually-killed-my-wife-patient-and-family-perspectives-shared-decision
    October 05, 2022 - Study 'I think this medicine actually killed my wife': patient and family perspectives on shared decision-making to optimize medications and safety. Citation Text: Mangin D, Risdon C, Lamarche L, et al. 'I think this medicine actually killed my wife': patient and family perspectives on s…

  12. Connecting patients and clinicians: the anticipated effects of Open Notes on patient safety and quality of care. | PSNet

    psnet.ahrq.gov/issue/connecting-patients-and-clinicians-anticipated-effects-open-notes-patient-safety-and-quality
    March 20, 2017 - Commentary Connecting patients and clinicians: the anticipated effects of Open Notes on patient safety and quality of care. Citation Text: Bell SK, Folcarelli PH, Anselmo MK, et al. Connecting patients and clinicians: the anticipated effects of Open Notes on patient safety and quality of…

  13. Empowerment failure: how shortcomings in physician communication unwittingly undermine patient autonomy. | PSNet

    psnet.ahrq.gov/issue/empowerment-failure-how-shortcomings-physician-communication-unwittingly-undermine-patient
    January 17, 2019 - Study Empowerment failure: how shortcomings in physician communication unwittingly undermine patient autonomy. Citation Text: Ubel PA, Scherr KA, Fagerlin A. Empowerment Failure: How Shortcomings in Physician Communication Unwittingly Undermine Patient Autonomy. Am J Bioeth. 2017;17(11):…

  14. Laboratory medicine handoff gaps experienced by primary care practices: a report from the Shared Networks of Collaborative Ambulatory Practices and Partners (SNOCAP). | PSNet

    psnet.ahrq.gov/issue/laboratory-medicine-handoff-gaps-experienced-primary-care-practices-report-shared-networks
    September 01, 2012 - Study Laboratory medicine handoff gaps experienced by primary care practices: a report from the Shared Networks of Collaborative Ambulatory Practices and Partners (SNOCAP). Citation Text: West DR, James KA, Fernald DH, et al. Laboratory medicine handoff gaps experienced by primary care p…

  15. National hospital ratings systems share few common scores and may generate confusion instead of clarity. | PSNet

    psnet.ahrq.gov/issue/national-hospital-ratings-systems-share-few-common-scores-and-may-generate-confusion-instead
    October 31, 2014 - Study Classic National hospital ratings systems share few common scores and may generate confusion instead of clarity. Citation Text: Austin M, Jha AK, Romano PS, et al. National hospital ratings systems share few common scores and may generate confusion instead…

  16. Rapid Response Systems | PSNet

    psnet.ahrq.gov/curated-library/rapid-response-systems
    September 15, 2024 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Rapid Response Systems  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: AHRQ Date Created: January 24, 20…

  17. Diagnostic Errors Case Studies | PSNet

    psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
    September 15, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Diagnostic Errors Case Studies  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Maria Mirica, PRIDE Group …

  18. You're the boss at the hospital. | PSNet

    psnet.ahrq.gov/issue/youre-boss-hospital
    February 28, 2024 - Newspaper/Magazine Article You're the boss at the hospital. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL November 28, 2016 This article shares guidelines for accompanying a fa…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836746/psn-pdf
    March 16, 2022 - Medicines reconciliation in the emergency department: important prescribing discrepancies between the shared medication record and patients' actual use of medication. March 16, 2022 Andersen TS, Gemmer MN, Sejberg HRC, et al. Medicines reconciliation in the emergency department: important prescribing discrepancies…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842765/psn-pdf
    January 18, 2023 - Patient identification of diagnostic safety blindspots and participation in "good catches" through shared visit notes. January 18, 2023 Bell SK, Bourgeois FC, Dong J, et al. Patient identification of diagnostic safety blindspots and participation in "good catches" through shared visit notes. Milbank Q. 2022;100(4)…
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