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psnet.ahrq.gov/issue/developing-high-performance-team-training-framework-internal-medicine-residents-abcs-teamwork
June 01, 2011 - September 11, 2013
Medication safety messages for patients via the web portal: the MedCheck … safety, learning environments, and relationships with continuity patients. … December 12, 2018
The effect of workload reduction on the quality of residents' discharge … Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey … February 18, 2011
Improving safety culture on adult medical units through multidisciplinary
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psnet.ahrq.gov/issue/proposed-2022-cdc-clinical-practice-guideline-prescribing-opioids-notice-centers-disease
December 21, 2022 - Agency Information Collection Activities: Proposed Collection; Comment Request, "Hospital Survey … on Patient Safety Culture Comparative Database.'' … opioid prescribing and patient pain in opioid-naive patients undergoing elective surgery in a large … April 17, 2019
Could CDC guidelines be driving some opioid patients to suicide? … March 20, 2019
Request for comments on the proposed measures and 2020 targets for the
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psnet.ahrq.gov/issue/sins-omission-getting-too-little-medical-care-may-be-greatest-threat-patient-safety
March 06, 2005 - of omission as they do on errors of commission. … January 22, 2017
Impact of the Comprehensive Unit-Based Safety Program (CUSP) on safety … culture in a surgical inpatient unit. … November 25, 2009
Transfers of patient care between house staff on internal medicine … wards: a national survey.
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psnet.ahrq.gov/issue/family-and-hospitals-journey-and-commitment-improving-diagnostic-safety
July 06, 2022 - Psychological Safety Scale of the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey … Leveraging a safety event management system to improve organizational learning and safety … culture. … and Creating a Safer Workplace
October 31, 2023
Perspectives on … August 3, 2022
Patients as diagnostic collaborators: sharing visit notes to promote accuracy
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psnet.ahrq.gov/issue/saying-sorry-some-strategies-effective-apology-within-workplace
August 11, 2021 - Effective apology behaviors improve opportunities for error resolution for clinicians , patients, … August 11, 2021
Ethical issues in patient safety research: a systematic review of the … March 31, 2021
The safety of emergency care systems: results of a survey of clinicians … June 25, 2010
Improving hospital safety culture for falls prevention through interdisciplinary … based on feedback from former psychiatric patients.
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psnet.ahrq.gov/issue/radiology-errors-are-we-learning-our-mistakes
May 26, 2011 - This survey study found that practicing radiologists and their departments have an opportunity to learn … commentary discussed a radiology "wet read" error that led to administration of thrombolytics in a patient … November 12, 2014
Inappropriate preinjury warfarin use in trauma patients: a call for … Learning from morbidity and mortality conferences: focus and sustainability of lessons for patient … Mortality and morbidity meetings: an untapped resource for improving the governance of patient
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psnet.ahrq.gov/issue/workplace-bullying-risk-and-safety-professionals
May 05, 2021 - In this survey study, researchers found that safety and risk professionals may be particularly vulnerable … September 20, 2023
Promoting patient safety: results of a TeamSTEPPS initiative. … maximizing training while sensing patient safety threats. … Findings from a UK multicentre survey study. … the adverse event rate in high risk medical and surgical patients.
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psnet.ahrq.gov/issue/effect-social-influences-pharmacists-intention-report-adverse-drug-events
November 13, 2019 - This survey explored factors that influence pharmacist reporting of medication errors and found that … 2019
Prescription opioid use, misuse, and use disorders in U.S. adults: 2015 National Survey … on Drug Use and Health. … January 6, 2016
An investigation of occupational subgroups with respect to patient safety … culture.
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psnet.ahrq.gov/issue/ashamed-admit-it-owning-medical-error
April 03, 2019 - February 28, 2024
National survey of patient safety experiences in hospital medicine … September 25, 2024
Drug-drug interactions and actual harm to hospitalized patients: a … April 10, 2024
The benefits and opportunities: engaging patients in identifying and reporting … patient safety incidents. … September 9, 2010
Disclosing medical errors to patients: a challenge for health care
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psnet.ahrq.gov/issue/implementing-smart-infusion-pumps-dose-error-reduction-software-real-world-experiences
May 26, 2021 - Smart pumps play an important role in preventing medication errors, but they can also introduce patient … August 28, 2019
Patient Safety: Emerging Applications of Safety Science. … - an international survey. … July 10, 2024
Family medicine presence on labor and delivery: effect on safety culture … March 27, 2024
Overnight stay in the emergency department and mortality in older patients
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psnet.ahrq.gov/issue/automated-dispensing-cabinets
September 27, 2010 - Drawing on Patient Safety Authority reports, this commentary discusses common errors with automated … August 28, 2019
Improved safety culture and teamwork climate are associated with decreases … 23, 2020
Raising the alarm: a cross-sectional study exploring the factors affecting patients … ' willingness to escalate care on surgical wards. … Preventing dispensing errors by alerting for drug confusions in the pharmacy information system—a survey
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psnet.ahrq.gov/issue/improving-inpatient-mental-health-medication-safety-through-process-obtaining-himss-stage-7
July 17, 2019 - Electronic health records (EHRs) have been widely adopted as a strategy to improve patient safety. … March 22, 2023
Hospital Survey on Patient Safety Culture: 2011 User Comparative Database … 27, 2024
Investigating the impact of cognitive bias in nursing documentation on … based on feedback from former psychiatric patients. … April 8, 2020
Special Issue on Medication Safety.
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psnet.ahrq.gov/issue/developing-person-centred-analysis-harm-paediatric-hospital-quality-improvement-report
September 23, 2020 - Through an iterative process, researchers developed and tested a simple tool for patients and family … improvements in staff reporting and other safety behaviors, but there was no measurable change in safety … culture scores for the ward during the study period. … the Huddle Observation Tool for structured case management discussions to improve situation awareness on … December 14, 2016
A national physician survey of diagnostic error in paediatrics.
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psnet.ahrq.gov/node/38582/psn-pdf
May 22, 2023 - https://psnet.ahrq.gov/issue/serious-reportable-events-massachusetts
This reoccurring report compiles patient … serious-reportable-events-healthcare-2011-update
https://psnet.ahrq.gov/issue/ambulatory-surgery-center-survey-patient-safety-culture
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psnet.ahrq.gov/issue/improving-patient-safety-hospitals-contributions-high-reliability-theory-and-normal-accident
October 13, 2010 - Commentary
Improving patient safety in hospitals: contributions of high-reliability … Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on … September 24, 2017
Effect of day of the week on short- and long-term mortality after … June 8, 2011
Development of a high-value care culture survey: a modified Delphi process … May 4, 2014
Oversight Hearing on Recent Patient Safety Issues.
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psnet.ahrq.gov/issue/smart-pump-custom-concentrations-without-hard-low-concentration-alerts
June 10, 2018 - June 10, 2018
Results of ISMP survey on high-alert medications: differences between nursing … February 13, 2019
Prescription drug time guarantees and their impact on patient safety … June 10, 2018
Results of our survey on drug storage, stability, compatibility, and beyond … October 31, 2012
IV vincristine survey shows safety improvements needed. … December 30, 2014
Missed medication doses in hospitalised patients: a descriptive account
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psnet.ahrq.gov/issue/system-errors-intrapartum-electronic-fetal-monitoring-case-review
May 16, 2012 - February 7, 2024
Effect of an emergency department process improvement package on suicide … October 10, 2018
Role-modeling and medical error disclosure: a national survey of trainees … June 25, 2010
Perceptions of safety culture vary across the intensive care units of a … A qualitative evaluation of healthcare professionals' perceptions of adverse events focusing on … September 29, 2010
Communication and teamwork in patient care: how much can we learn
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psnet.ahrq.gov/issue/perchance-think
December 08, 2016 - February 28, 2024
National survey of patient safety experiences in hospital medicine … September 25, 2024
Drug-drug interactions and actual harm to hospitalized patients: a … April 10, 2024
The benefits and opportunities: engaging patients in identifying and reporting … patient safety incidents. … April 10, 2019
WebM&M Cases
What Happened on Telemetry
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psnet.ahrq.gov/issue/multiple-patient-safety-events-within-single-hospitalization-national-profile-us-hospitals
November 13, 2009 - July 10, 2017
Adverse-event-reporting practices by US hospitals: results of a national survey … September 12, 2012
A review of patient safety measures based on routinely collected hospital … April 18, 2012
Effect of illness severity and comorbidity on patient safety and adverse … March 3, 2011
Exploring relationships between hospital patient safety culture and adverse … September 2, 2009
Impact of date stamping on patient safety measurement in patients undergoing
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psnet.ahrq.gov/issue/how-major-public-hospital-protecting-doctors-silencing-patients-who-accuse-them
January 24, 2024 - Citation Text:
How a major public hospital is protecting doctors by silencing the patients who accuse … Transparency is a primary element of an organizational safety culture that enables recognition of medical … error to inform improvement and responsible redress for the patient and family. … May 27, 2020
Survey by Ohio regulator shows stress, fatigue among pharmacists at chain … safety risks to reporting patient complaints: a grounded theory study on patients' hospital experiences