-
psnet.ahrq.gov/node/46764/psn-pdf
March 28, 2018 - The Report of the Short Life Working Group on Reducing
Medication-related Harm.
March 28, 2018
Department of Health and Social Care. London, England: Crown Publishing; February 2018.
https://psnet.ahrq.gov/issue/report-short-life-working-group-reducing-medication-related-harm
Medication errors are a prominent chal…
-
psnet.ahrq.gov/node/44375/psn-pdf
August 05, 2015 - 12 h shifts and rates of error among nurses: a systematic
review.
August 5, 2015
Clendon J, Gibbons V. 12 h shifts and rates of error among nurses: a systematic review. Int J Nurs Stud.
2015;52(7):1231-1242. doi:10.1016/j.ijnurstu.2015.03.011.
https://psnet.ahrq.gov/issue/12-h-shifts-and-rates-error-among-nurses-…
-
psnet.ahrq.gov/node/39605/psn-pdf
December 17, 2010 - The effect of facility complexity on perceptions of safety
climate in the operating room: size matters.
December 17, 2010
Carney BT, West P, Neily J, et al. The effect of facility complexity on perceptions of safety climate in the
operating room: size matters. Am J Med Qual. 2010;25(6):457-61. doi:10.1177/106286061…
-
psnet.ahrq.gov/node/45799/psn-pdf
May 09, 2017 - Assessing frequency and risk of weight entry errors in
pediatrics.
May 9, 2017
Hagedorn PA, Kirkendall E, Kouril M, et al. Assessing Frequency and Risk of Weight Entry Errors in
Pediatrics. JAMA Pediatr. 2017;171(4):392-393. doi:10.1001/jamapediatrics.2016.3865.
https://psnet.ahrq.gov/issue/assessing-frequency-and…
-
psnet.ahrq.gov/node/46501/psn-pdf
March 20, 2018 - Blind obedience and an unnecessary workup for
hypoglycemia: a teachable moment.
March 20, 2018
Wang EY, Patrick L, Connor DM. Blind Obedience and an Unnecessary Workup for Hypoglycemia: A
Teachable Moment. JAMA Intern Med. 2018;178(2):279-280. doi:10.1001/jamainternmed.2017.7104.
https://psnet.ahrq.gov/issue/blind…
-
psnet.ahrq.gov/node/35069/psn-pdf
June 22, 2009 - Towards an organization with a memory: exploring the
organizational generation of adverse events in health
care.
June 22, 2009
Smith D, Toft B. Towards an organization with a memory: exploring the organizational generation of
adverse events in health care. Health Serv Manage Res. 2005;18(2). doi:10.1258/0951484053…
-
psnet.ahrq.gov/node/45785/psn-pdf
September 29, 2017 - Traditions of research into interruptions in healthcare: a
conceptual review.
September 29, 2017
McCurdie T, Sanderson P, Aitken LM. Traditions of research into interruptions in healthcare: A conceptual
review. Int J Nurs Stud. 2017;66:23-36. doi:10.1016/j.ijnurstu.2016.11.005.
https://psnet.ahrq.gov/issue/traditi…
-
psnet.ahrq.gov/node/45925/psn-pdf
April 19, 2017 - All consumer medication information is not created equal:
implications for medication safety.
April 19, 2017
Monkman H, Kushniruk AW. All Consumer Medication Information Is Not Created Equal: Implications for
Medication Safety. Stud Health Technol Inform. 2017;234:233-237.
https://psnet.ahrq.gov/issue/all-consumer…
-
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…
-
psnet.ahrq.gov/node/45035/psn-pdf
January 23, 2017 - Premature closure? Not so fast.
January 23, 2017
Dhaliwal G. Premature closure? Not so fast. BMJ Qual Saf. 2017;26(2):87-89. doi:10.1136/bmjqs-2016-
005267.
https://psnet.ahrq.gov/issue/premature-closure-not-so-fast
Analyzing clinician decision making is increasingly suggested as a strategy to reduce diagnostic er…
-
psnet.ahrq.gov/node/43047/psn-pdf
August 02, 2015 - Hospital readmission after noncardiac surgery: the role of
major complications.
August 2, 2015
Glance LG, Kellermann AL, Osler T, et al. Hospital readmission after noncardiac surgery: the role of major
complications. JAMA Surg. 2014;149(5):439-45.
https://psnet.ahrq.gov/issue/hospital-readmission-after-noncardiac-…
-
psnet.ahrq.gov/node/45903/psn-pdf
June 21, 2017 - Association between state medical malpractice
environment and postoperative outcomes in the United
States.
June 21, 2017
Minami CA, Sheils CR, Pavey E, et al. Association Between State Medical Malpractice Environment and
Postoperative Outcomes in the United States. J Am Coll Surg. 2017;224(3):310-318.e2.
doi:10.1…
-
psnet.ahrq.gov/node/46259/psn-pdf
September 24, 2017 - A qualitative formative evaluation of a patient-centred
patient safety intervention delivered in collaboration with
hospital volunteers.
September 24, 2017
Louch G, O'Hara JK, Mohammed MA. A qualitative formative evaluation of a patient-centred patient safety
intervention delivered in collaboration with hospital v…
-
psnet.ahrq.gov/node/45618/psn-pdf
April 24, 2018 - Electronic detection of delayed test result follow-up in
patients with hypothyroidism.
April 24, 2018
Meyer AND, Murphy DR, Al-Mutairi A, et al. Electronic Detection of Delayed Test Result Follow-Up in
Patients with Hypothyroidism. J Gen Intern Med. 2017;32(7). doi:10.1007/s11606-017-3988-z.
https://psnet.ahrq.gov…
-
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…
-
psnet.ahrq.gov/node/34800/psn-pdf
December 23, 2008 - A classification system for incidents and accidents in the
health-care system.
December 23, 2008
Runciman WB, Helps SC, Sexton EJ, et al. A classification for incidents and accidents in the health-care
system. J Qual Clin Pract. 1998;18(3):199-211.
https://psnet.ahrq.gov/issue/classification-system-incidents-and-a…
-
psnet.ahrq.gov/node/60669/psn-pdf
July 08, 2020 - Participation in a system-thinking simulation experience
changes adverse event reporting.
July 8, 2020
Sanko JS, Mckay M. Participation in a system-thinking simulation experience changes adverse event
reporting. Simul Healthc. 2020;15(3):167-171. doi:10.1097/sih.0000000000000473.
https://psnet.ahrq.gov/issue/parti…
-
psnet.ahrq.gov/node/45297/psn-pdf
July 13, 2016 - Evaluation of 12 strategies for obtaining second opinions
to improve interpretation of breast histopathology:
simulation study.
July 13, 2016
Elmore JG, Tosteson AN, Pepe MS, et al. Evaluation of 12 strategies for obtaining second opinions to
improve interpretation of breast histopathology: simulation study. BMJ. …
-
psnet.ahrq.gov/node/34643/psn-pdf
December 23, 2008 - The health care cost of drug-related morbidity and
mortality in nursing facilities.
December 23, 2008
Bootman JL, Harrison DL, Cox E. The health care cost of drug-related morbidity and mortality in nursing
facilities. Arch Intern Med. 1997;157(18):2089-96.
https://psnet.ahrq.gov/issue/health-care-cost-drug-related…
-
psnet.ahrq.gov/node/39840/psn-pdf
September 15, 2010 - Wrong-site craniotomy: analysis of 35 cases and systems
for prevention.
September 15, 2010
Cohen FL, Mendelsohn D, Bernstein M. Wrong-site craniotomy: analysis of 35 cases and systems for
prevention. J Neurosurg. 2010;113(3):461-73. doi:10.3171/2009.10.JNS091282.
https://psnet.ahrq.gov/issue/wrong-site-craniotomy-…