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psnet.ahrq.gov/node/33764/psn-pdf
April 01, 2014 - Is there a way to get some best practice standards out there to help people optimize these
things?
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psnet.ahrq.gov/node/837607/psn-pdf
June 29, 2022 - Common Formats for Event Reporting - Diagnostic Safety
Version 1.0
June 29, 2022
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/common-formats-event-reporting-diagnostic-safety-version-10
Effective measurement of diagnostic error is essential for understanding the problem and genera…
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psnet.ahrq.gov/node/42413/psn-pdf
July 31, 2013 - A handoff protocol from the cardiovascular operating
room to cardiac ICU is associated with improvements in
care beyond the immediate postoperative period.
July 31, 2013
Kaufmnan J, Twite M, Barrett C, et al. A handoff protocol from the cardiovascular operating room to cardiac
ICU is associated with improvements i…
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psnet.ahrq.gov/node/38945/psn-pdf
November 25, 2009 - The negative impact of nurse-physician disruptive
behavior on patient safety: a review of the literature.
November 25, 2009
Saxton R, Hines T, Enriquez M. The negative impact of nurse-physician disruptive behavior on patient
safety: a review of the literature. J Patient Saf. 2009;5(3):180-183. doi:10.1097/pts.0b013…
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psnet.ahrq.gov/node/40349/psn-pdf
May 11, 2011 - Use of briefings and debriefings as a tool in improving
team work, efficiency, and communication in the
operating theatre.
May 11, 2011
Bethune R, Sasirekha G, Sahu A, et al. Use of briefings and debriefings as a tool in improving team work,
efficiency, and communication in the operating theatre. Postgrad Med J. 2…
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psnet.ahrq.gov/node/41685/psn-pdf
July 02, 2014 - Faculty member review and feedback using a sign-out
checklist: improving intern written sign-out.
July 2, 2014
Bump GM, Bost JE, Buranosky R, et al. Faculty member review and feedback using a sign-out checklist:
improving intern written sign-out. Acad Med. 2012;87(8):1125-31. doi:10.1097/ACM.0b013e31825d1215.
http…
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psnet.ahrq.gov/node/37135/psn-pdf
October 04, 2011 - Combining ratings from multiple physician reviewers
helped to overcome the uncertainty associated with
adverse event classification.
October 4, 2011
Forster AJ, O'Rourke K, Shojania KG, et al. Combining ratings from multiple physician reviewers helped to
overcome the uncertainty associated with adverse event class…
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psnet.ahrq.gov/node/35749/psn-pdf
May 09, 2014 - Chemotherapy dose limits set by users of a computer
order entry system.
May 9, 2014
DuBeshter B; Griggs J; Angel C; Loughner J.
https://psnet.ahrq.gov/issue/chemotherapy-dose-limits-set-users-computer-order-entry-system
To avoid excessive dosing of chemotherapeutic agents, standardized dose limits must be agreed u…
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psnet.ahrq.gov/node/44057/psn-pdf
June 03, 2015 - Measuring nursing error: psychometrics of MISSCARE
and practice and professional issues items.
June 3, 2015
Castner J, Dean-Baar S. Measuring nursing error: psychometrics of MISSCARE and practice and
professional issues items. J Nurs Manag. 2014;22(3):421-437.
https://psnet.ahrq.gov/issue/measuring-nursing-error-p…
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psnet.ahrq.gov/node/864385/psn-pdf
April 05, 2024 - Common Formats for Patient Safety Data Collection.
March 13, 2024
Agency for Healthcare Research and Quality. Fed Register. Mar 6, 2024;89(45);15992.
https://psnet.ahrq.gov/issue/common-formats-patient-safety-data-collection
A standard system for voluntary reporting to patient safety organizations improves measurem…
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psnet.ahrq.gov/node/44701/psn-pdf
June 07, 2016 - The problem with preventable deaths.
June 7, 2016
Hogan H. The problem with preventable deaths. BMJ Qual Saf. 2016;25(5):320-3. doi:10.1136/bmjqs-
2015-004983.
https://psnet.ahrq.gov/issue/problem-preventable-deaths
A key goal of patient safety improvement is preventing error, but challenges remain in distinguishi…
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psnet.ahrq.gov/node/47643/psn-pdf
February 20, 2019 - Pro/con debate: color-coded medication labels.
February 20, 2019
Janik LS, Vender JS, Grissinger M, Litman RS. APSF Newsletter. February 2019;33:72-75.
https://psnet.ahrq.gov/issue/procon-debate-color-coded-medication-labels
This pair of commentaries reviews the use of color-coded medications as an anesthesia safe…
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psnet.ahrq.gov/node/60831/psn-pdf
August 19, 2020 - Telediagnosis for Acute Care: Implications for the Quality
and Safety of Diagnosis.
August 19, 2020
Smith KM, Hunte HE, Graber ML. Rockville MD: Agency for Healthcare Research and Quality; August
2020. AHRQ Publication No. 20-0040-2-EF.
https://psnet.ahrq.gov/issue/telediagnosis-acute-care-implications-quality-and…
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psnet.ahrq.gov/node/47620/psn-pdf
January 16, 2019 - Factors underlying suboptimal diagnostic performance in
physicians under time pressure.
January 16, 2019
ALQahtani DA, Rotgans JI, Mamede S, et al. Factors underlying suboptimal diagnostic performance in
physicians under time pressure. Med Educ. 2018;52(12):1288-1298. doi:10.1111/medu.13686.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/43096/psn-pdf
August 22, 2016 - Rapid learning of adverse medical event disclosure and
apology.
August 22, 2016
Raemer D, Locke S, Walzer TB, et al. Rapid Learning of Adverse Medical Event Disclosure and Apology. J
Patient Saf. 2016;12(3):140-7. doi:10.1097/PTS.0000000000000080.
https://psnet.ahrq.gov/issue/rapid-learning-adverse-medical-event-d…
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psnet.ahrq.gov/node/44058/psn-pdf
July 03, 2016 - Metric units and the preferred dosing of orally
administered liquid medications.
July 3, 2016
Metric Units and the Preferred Dosing of Orally Administered Liquid Medications. doi:10.1542/peds.2015-
0072.
https://psnet.ahrq.gov/issue/metric-units-and-preferred-dosing-orally-administered-liquid-medications
Accident…
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psnet.ahrq.gov/node/34950/psn-pdf
June 23, 2009 - Competition and health plan performance: evidence from
health maintenance organization insurance markets.
June 23, 2009
Scanlon D, Swaminathan S, Chernew M, et al. Competition and health plan performance: evidence from
health maintenance organization insurance markets. Med Care. 2005;43(4):338-346.
https://psnet.a…
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psnet.ahrq.gov/node/41577/psn-pdf
September 27, 2016 - Nursing perception of the impact of medication carts on
patient safety and ergonomics in a teaching health care
center.
September 27, 2016
Rochais E, Atkinson S, Bussières J-F. Nursing perception of the impact of medication carts on patient
safety and ergonomics in a teaching health care center. J Pharm Pract. 201…
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psnet.ahrq.gov/node/47135/psn-pdf
July 25, 2018 - Structured patient handoff on an internal medicine ward:
a cluster randomized control trial.
July 25, 2018
Tam P, Nijjar AP, Fok M, et al. Structured patient handoff on an internal medicine ward: A cluster
randomized control trial. PLoS One. 2018;13(4):e0195216. doi:10.1371/journal.pone.0195216.
https://psnet.ahrq…
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psnet.ahrq.gov/node/862610/psn-pdf
February 14, 2024 - Assessing the safety of a new clinical decision support
system for a national helpline.
February 14, 2024
Luckraj N, Strazzari R, Coiera E, et al. Assessing the safety of a new clinical decision support system for a
national helpline. Stud Health Technol Inform. 2024;310:514-518. doi:10.3233/shti231018.
https://ps…