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psnet.ahrq.gov/node/851654/psn-pdf
July 26, 2023 - Antimicrobial residual drug error in the intensive care
unit; a single blinded prospective observational study.
July 26, 2023
Jarrett P, Keogh S, Roberts JA, et al. Antimicrobial residual drug error in the intensive care unit; a single
blinded prospective observational study. Intensive Crit Care Nurs. 2023;77:10340…
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psnet.ahrq.gov/node/73075/psn-pdf
March 24, 2021 - Analysis of transdermal medication patch errors
uncovers a “patchwork” of safety challenges.
March 24, 2021
ISMP Medication Safety Alert! Acute Care. March 11, 2021;26(5):1-6.
https://psnet.ahrq.gov/issue/analysis-transdermal-medication-patch-errors-uncovers-patchwork-safety-
challenges
Skin patches are a conveni…
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psnet.ahrq.gov/node/73148/psn-pdf
April 14, 2021 - 10 Leadership mindsets for high reliability organizations.
How to empower caregivers and engage patients in
patient safety.
April 14, 2021
Jurecko L. Consult QD. March 16, 2021.
https://psnet.ahrq.gov/issue/10-leadership-mindsets-high-reliability-organizations-how-empower-caregivers-
and-engage
Leadership a…
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psnet.ahrq.gov/node/43324/psn-pdf
July 23, 2014 - Incidence of adverse events in an integrated US
healthcare system: a retrospective observational study of
82,784 surgical hospitalizations.
July 23, 2014
Zeeshan MF, Dembe AE, Seiber EE, et al. Incidence of adverse events in an integrated US healthcare
system: a retrospective observational study of 82,784 surgical…
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psnet.ahrq.gov/node/40654/psn-pdf
January 01, 2012 - The computerized rounding report: implementation of a
model system to support transitions of care.
December 15, 2011
Wohlauer M, Rove KO, Pshak TJ, et al. The computerized rounding report: implementation of a model
system to support transitions of care. J Surg Res. 2012;172(1):11-7. doi:10.1016/j.jss.2011.04.015.
…
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psnet.ahrq.gov/node/73706/psn-pdf
September 15, 2021 - A meta-review of methods of measuring and monitoring
safety in primary care.
September 15, 2021
O’Connor P, Madden C, O’Dowd E, et al. A meta-review of methods of measuring and monitoring safety in
primary care. Int J Qual Health Care. 2021;33(3):mzab117. doi:10.1093/intqhc/mzab117.
https://psnet.ahrq.gov/issue/me…
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psnet.ahrq.gov/node/43556/psn-pdf
December 19, 2014 - Establishing a safe container for learning in simulation:
the role of the presimulation briefing.
December 19, 2014
Rudolph JW, Raemer D, Simon R. Establishing a safe container for learning in simulation: the role of the
presimulation briefing. Simul Healthc. 2014;9(6):339-49. doi:10.1097/SIH.0000000000000047.
htt…
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psnet.ahrq.gov/node/45173/psn-pdf
November 18, 2016 - Impact of hospital-acquired conditions on financial
liabilities for Medicare patients.
November 18, 2016
Coomer NM, Kandilov AMG. Impact of hospital-acquired conditions on financial liabilities for Medicare
patients. Am J Infect Control. 2016;44(11):1326-1334. doi:10.1016/j.ajic.2016.03.025.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/47881/psn-pdf
July 10, 2019 - Cognitive Errors and Diagnostic Mistakes: A Case-Based
Guide to Critical Thinking in Medicine.
July 10, 2019
Howard J. Cham, Switzerland: Springer Nature Switzerland; 2019. ISBN: 9783319932231.
https://psnet.ahrq.gov/issue/cognitive-errors-and-diagnostic-mistakes-case-based-guide-critical-thinking-
medicine
Cogni…
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psnet.ahrq.gov/node/854379/psn-pdf
October 11, 2023 - The limits of psychological safety: nonlinear relationships
with performance.
October 11, 2023
Eldor L, Hodor M, Cappelli P. The limits of psychological safety: nonlinear relationships with performance.
Org Behav Human Decision Proc. 2023;177:104255. doi:10.1016/j.obhdp.2023.104255.
https://psnet.ahrq.gov/issue/li…
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psnet.ahrq.gov/node/838030/psn-pdf
September 07, 2022 - Rethinking use of air-safety principles to reduce fatal
hospital errors.
September 7, 2022
Rethinking use of air-safety principles to reduce fatal hospital errors.
doi:10.1377/forefront.20220824.965364.
https://psnet.ahrq.gov/issue/rethinking-use-air-safety-principles-reduce-fatal-hospital-errors
The safety of co…
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psnet.ahrq.gov/node/46248/psn-pdf
October 23, 2018 - Medical errors, malpractice, and defensive medicine: an
ill-fated triad.
October 23, 2018
Berlin L. Medical errors, malpractice, and defensive medicine: an ill-fated triad. Diagnosis (Berl).
2017;4(3):133-139. doi:10.1515/dx-2017-0007.
https://psnet.ahrq.gov/issue/medical-errors-malpractice-and-defensive-medicine-…
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psnet.ahrq.gov/node/45018/psn-pdf
November 18, 2016 - Identifying risk in the use of tumor markers to improve
patient safety.
November 18, 2016
Moreno-Campoy EE, De la Torre FJM-, Martos-Crespo F, et al. Identifying risk in the use of tumor markers
to improve patient safety. Clin Chem Lab Med. 2016;54(12):1947-1953. doi:10.1515/cclm-2015-0760.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/44682/psn-pdf
March 15, 2016 - On resident duty hour restrictions and neurosurgical
training: review of the literature.
March 15, 2016
Bina RW, Lemole M, Dumont TM. On resident duty hour restrictions and neurosurgical training: review of
the literature. J Neurosurg. 2016;124(3):842-8. doi:10.3171/2015.3.JNS142796.
https://psnet.ahrq.gov/issue/r…
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psnet.ahrq.gov/node/38781/psn-pdf
July 15, 2009 - Medical errors and consequent adverse events in
critically ill surgical patients in a tertiary care teaching
hospital in Delhi.
July 15, 2009
Kumar S, Chaudhary S. Medical errors and consequent adverse events in critically ill surgical patients in a
tertiary care teaching hospital in Delhi. J Emerg Trauma Shock. 2…
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psnet.ahrq.gov/node/46392/psn-pdf
October 13, 2018 - The clinical and medicolegal implications of radiology
results communication.
October 13, 2018
Aryal B, Khorsand DA, Dubinsky TJ. The Clinical and Medicolegal Implications of Radiology Results
Communication. Curr Probl Diagn Radiol. 2018;47(5):287-289. doi:10.1067/j.cpradiol.2017.09.009.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/34062/psn-pdf
February 18, 2011 - Adverse drug events in ambulatory care.
February 18, 2011
Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. New Engl J Med.
2003;348(16):1556-1564.
https://psnet.ahrq.gov/issue/adverse-drug-events-ambulatory-care
This prospective cohort study evaluated more than 1200 outpatient prescr…
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psnet.ahrq.gov/node/848383/psn-pdf
May 03, 2023 - Burnout in Primary Care: Assessing and Addressing It in
Your Practice.
May 3, 2023
Gerteis J, Booker C, Brach C, et al. Rockville, MD: Agency for Healthcare Research and Quality;
February 2023. AHRQ Publication No. 23-0025.
https://psnet.ahrq.gov/issue/burnout-primary-care-assessing-and-addressing-it-your-pr…
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www.ahrq.gov/talkingquality/assess/index.html
September 01, 2019 - Assess Your Health Care Quality Reporting Project
Reporting comparative quality information to consumers is typically not a one-time event but an ongoing activity. For this reason, evaluation is a key part of your work, an aspect that has to be thought about and, in some cases, acted upon from the outset.
An …
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www.ahrq.gov/hai/tools/enhanced-recovery/overview.html
June 01, 2023 - Overview
Tools and Resources To Help Hospitals Choose an ISCR Program
This section gives a high-level overview of the Improving Surgical Care and Recovery (ISCR) program to support hospitals in implementing evidence-based enhanced recovery pathways. The Overview lists the tools and materials, organized in the…