-
psnet.ahrq.gov/node/848809/psn-pdf
May 10, 2023 - Improving safety during transitions of care through the
use of electronic referral loops to receive and reconcile
health information.
May 10, 2023
Allen G, Setzer J, Jones R, et al. Improving safety during transitions of care through the use of electronic
referral loops to receive and reconcile health information.…
-
psnet.ahrq.gov/node/45967/psn-pdf
July 05, 2017 - Root-cause analysis: swatting at mosquitoes versus
draining the swamp.
July 5, 2017
Trbovich PL, Shojania KG. Root-cause analysis: swatting at mosquitoes versus draining the swamp. BMJ
Qual Saf. 2017;26(5):350-353. doi:10.1136/bmjqs-2016-006229.
https://psnet.ahrq.gov/issue/root-cause-analysis-swatting-mosquitoes-…
-
psnet.ahrq.gov/node/45964/psn-pdf
March 22, 2017 - What is known: examining the empirical literature in
resident work hours using 30 influential articles.
March 22, 2017
Philibert I. What Is Known: Examining the Empirical Literature in Resident Work Hours Using 30 Influential
Articles. J Grad Med Educ. 2016;8(5):795-805. doi:10.4300/JGME-D-16-00642.1.
https://psne…
-
psnet.ahrq.gov/node/45914/psn-pdf
March 20, 2018 - Understanding the multidimensional effects of resident
duty hours restrictions: a thematic analysis of published
viewpoints in surgery.
March 20, 2018
Devitt KS, Kim MJ, Conn LG, et al. Understanding the Multidimensional Effects of Resident Duty Hours
Restrictions: A Thematic Analysis of Published Viewpoints in Su…
-
psnet.ahrq.gov/node/844058/psn-pdf
February 08, 2023 - ISMP updates its list of drug names with tall man (mixed
case) letters based on survey results.
February 8, 2023
ISMP Medication Safety Alert! Acute care edition. January 26, 2023:28(2):1-4.
https://psnet.ahrq.gov/issue/ismp-updates-its-list-drug-names-tall-man-mixed-case-letters-based-survey-
results
Look-a…
-
psnet.ahrq.gov/node/45238/psn-pdf
September 29, 2017 - Unprofessional behaviors among tomorrow's physicians:
review of the literature with a focus on risk factors,
temporal trends, and future directions.
September 29, 2017
Fargen KM, Drolet BC, Philibert I. Unprofessional Behaviors Among Tomorrow's Physicians: Review of the
Literature With a Focus on Risk Factors, Tem…
-
psnet.ahrq.gov/node/48101/psn-pdf
August 14, 2019 - Partnering with families and patient advocates: another
line of defense in adverse event surveillance.
August 14, 2019
ISMP Medication Safety Alert! Acute Care Edition. August 1, 2019;24.
https://psnet.ahrq.gov/issue/partnering-families-and-patient-advocates-another-line-defense-adverse-event-
surveillance
Having…
-
psnet.ahrq.gov/node/44098/psn-pdf
April 29, 2015 - Evaluation of the suitability of root cause analysis
frameworks for the investigation of community-acquired
pressure ulcers: a systematic review and documentary
analysis.
April 29, 2015
McGraw C, Drennan VM. Evaluation of the suitability of root cause analysis frameworks for the
investigation of community-acquire…
-
psnet.ahrq.gov/node/45700/psn-pdf
September 01, 2018 - Resolving malpractice claims after tort reform: experience
in a self-insured Texas public academic health system.
September 1, 2018
Sage WM, Harding MC, Thomas EJ. Resolving Malpractice Claims after Tort Reform: Experience in a Self-
Insured Texas Public Academic Health System. Health Serv Res. 2016;51 Suppl 3:2615…
-
psnet.ahrq.gov/node/45045/psn-pdf
May 25, 2016 - Developing and Testing the Health Care Safety Hotline: A
Prototype Consumer Reporting System for Patient Safety
Events. Final Report.
May 25, 2016
Schneider EC, Ridgely MS, Quigley DD, et al. Rockville, MD: Agency for Healthcare Research and Quality;
May 2016. AHRQ Publication No. 16-0027-EF.
https://psnet.ahrq.g…
-
psnet.ahrq.gov/node/74033/psn-pdf
November 03, 2021 - Identifying electronic medication administration record
(eMAR) usability issues from patient safety event reports.
November 3, 2021
Iqbal AR, Parau CA, Kazi S, et al. Identifying electronic medication administration record (eMAR) usability
issues from patient safety event reports. Jt Comm J Qual Patient Saf. 2021;4…
-
psnet.ahrq.gov/node/46532/psn-pdf
July 30, 2018 - Efficiency and safety of speech recognition for
documentation in the electronic health record.
July 30, 2018
Hodgson T, Magrabi F, Coiera E. Efficiency and safety of speech recognition for documentation in the
electronic health record. J Am Med Inform Assoc. 2017;24(6):1127-1133. doi:10.1093/jamia/ocx073.
https://…
-
psnet.ahrq.gov/node/867596/psn-pdf
January 22, 2025 - Creation of root cause analysis and action (RCA2)
standard work by a multidisciplinary team to prevent
harm, reduce bias, and improve safety culture.
January 22, 2025
Musheno D, Harnish M, Roberts J, et al. Creation of root cause analysis and action (RCA2) standard work
by a multidisciplinary team to prevent harm,…
-
psnet.ahrq.gov/node/73676/psn-pdf
September 08, 2021 - Organizational readiness to change as a leverage point
for improving safety: a national nursing home survey.
September 8, 2021
Quach ED, Kazis LE, Zhao S, et al. Organizational readiness to change as a leverage point for improving
safety: a national nursing home survey. BMC Health Serv Res. 2021;21(1):842. doi:10.1…
-
psnet.ahrq.gov/node/44446/psn-pdf
June 21, 2016 - Collective intelligence meets medical decision-making:
the collective outperforms the best radiologist.
June 21, 2016
Wolf M, Krause J, Carney PA, et al. Collective intelligence meets medical decision-making: the collective
outperforms the best radiologist. PLoS One. 2015;10(8):e0134269. doi:10.1371/journal.pone.01…
-
psnet.ahrq.gov/node/37590/psn-pdf
April 13, 2018 - Just Culture: Restoring Trust and Accountability in Your
Organization, Third Edition.
April 13, 2018
Dekker S. Boca Raton, FL: CRC Press; 2017. ISBN: 9781472475756.
https://psnet.ahrq.gov/issue/just-culture-restoring-trust-and-accountability-your-organization-third-edition
Although early efforts in the patient saf…
-
psnet.ahrq.gov/node/44321/psn-pdf
July 08, 2015 - Move toward full use of metric dosing: eliminate dosage
cups that measure liquids in fluid drams. Use cups that
measure mL.
July 8, 2015
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American
Society of Health-System Pharmacists. June 30, 2015.
https://psnet.ahrq.gov/…
-
psnet.ahrq.gov/node/844544/psn-pdf
February 15, 2023 - Involving patients and carers in patient safety in primary
care: a qualitative study of a co-designed patient safety
guide.
February 15, 2023
Morris RL, Giles SJ, Campbell S. Involving patients and carers in patient safety in primary care: a
qualitative study of a co?designed patient safety guide. Health Expect. 2…
-
psnet.ahrq.gov/node/72508/psn-pdf
January 01, 2021 - Helping healthcare teams save lives during COVID-19:
insights and countermeasures from team science.
November 25, 2020
Traylor AM. Helping healthcare teams save lives during COVID-19: insights and countermeasures from
team science. Am Psychol. 2021;76(1):1-13. doi:10.1037/amp0000750.
https://psnet.ahrq.gov/issue/h…
-
psnet.ahrq.gov/node/60612/psn-pdf
January 01, 2021 - COVID-19: patient safety and quality improvement skills
to deploy during the surge.
June 24, 2020
Staines A, Amalberti R, Berwick DM, et al. COVID-19: patient safety and quality improvement skills to
deploy during the surge. Int J Qual Health Care. 2021;33(1):mzaa050. doi:10.1093/intqhc/mzaa050.
https://psnet.ahrq…