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psnet.ahrq.gov/node/74188/psn-pdf
December 15, 2021 - Semantically ambiguous language in the teaching
operating room.
December 15, 2021
Liu C, McKenzie A, Sutkin G. Semantically ambiguous language in the teaching operating room. J Surg
Edu. 2021;78(6):1938-1947. doi:10.1016/j.jsurg.2021.03.020.
https://psnet.ahrq.gov/issue/semantically-ambiguous-language-teaching-ope…
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psnet.ahrq.gov/node/844542/psn-pdf
February 15, 2023 - Human factors in anaesthesia: a narrative review.
February 15, 2023
Kelly FE, Frerk C, Bailey CR, et al. Human factors in anaesthesia: a narrative review. Anaesthesia.
2023;78(4):479-490. doi:10.1111/anae.15920.
https://psnet.ahrq.gov/issue/human-factors-anaesthesia-narrative-review
Human factors science focuses o…
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psnet.ahrq.gov/node/43566/psn-pdf
December 19, 2014 - Bedside shift reports: what does the evidence say?
December 19, 2014
Gregory S, Tan D, Tilrico M, et al. Bedside shift reports: what does the evidence say? J Nurs Adm.
2014;44(10):541-5. doi:10.1097/NNA.0000000000000115.
https://psnet.ahrq.gov/issue/bedside-shift-reports-what-does-evidence-say
Bedside shift report…
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psnet.ahrq.gov/node/865883/psn-pdf
May 15, 2024 - Addressing electronic health record contributions to
diagnostic error.
May 15, 2024
Ratwani RM, Bates DW, Gold J. Health Affairs Forefront. April 25, 2024.
https://psnet.ahrq.gov/issue/addressing-electronic-health-record-contributions-diagnostic-error
Design and user issues are persistent detractors from the relia…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/infection-prevention/environment-and-equipment/all-staff-discussion.docx
March 01, 2017 - AHRQ Safety Program for
Long-Term Care: HAIs/CAUTI
Training Module 2 — All-Staff Discussion Guide
Clean Equipment and Environment Promote Safe Resident Care
Directions
Answer the following questions to help reflect on how you can prepare to discuss cleaning and disinfection practices at your facility.
Discussion Quest…
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psnet.ahrq.gov/node/43033/psn-pdf
March 12, 2014 - Current challenges and future perspectives for patient
safety in surgery.
March 12, 2014
Stahel PF, Mauffrey C, Butler N. Current challenges and future perspectives for patient safety in surgery.
Patient Saf Surg. 2014;8(1):9. doi:10.1186/1754-9493-8-9.
https://psnet.ahrq.gov/issue/current-challenges-and-future-pe…
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psnet.ahrq.gov/node/39505/psn-pdf
November 26, 2014 - Improving teamwork: impact of structured
interdisciplinary rounds on a medical teaching unit.
November 26, 2014
O'Leary KJ, Wayne DB, Haviley C, et al. Improving teamwork: impact of structured interdisciplinary rounds
on a medical teaching unit. J Gen Intern Med. 2010;25(8):826-32. doi:10.1007/s11606-010-1345-6.
h…
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psnet.ahrq.gov/node/837604/psn-pdf
June 29, 2022 - Diagnostic overshadowing among groups experiencing
health disparities.
June 29, 2022
Sentinel Event Alert. June 22, 2022;(65):1-7.
https://psnet.ahrq.gov/issue/diagnostic-overshadowing-among-groups-experiencing-health-disparities
A clinician's knowledge of an existing condition can implicitly affect treatment reco…
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psnet.ahrq.gov/node/73692/psn-pdf
September 08, 2021 - Quality and safety in surgery: challenges and
opportunities.
September 8, 2021
Nasca BJ, Bilimoria KY, Yang AD. Quality and safety in surgery: challenges and opportunities. Jt Comm J
Qual Patient Saf. 2021;47(9):604-607. doi:10.1016/j.jcjq.2021.05.003.
https://psnet.ahrq.gov/issue/quality-and-safety-surgery-challe…
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psnet.ahrq.gov/node/47936/psn-pdf
June 14, 2019 - A team disclosure of error educational activity: objective
outcomes.
June 14, 2019
Krumwiede KH, Wagner JM, Kirk LM, et al. A Team Disclosure of Error Educational Activity: Objective
Outcomes. J Am Geriatr Soc. 2019;67(6):1273-1277. doi:10.1111/jgs.15883.
https://psnet.ahrq.gov/issue/team-disclosure-error-educatio…
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psnet.ahrq.gov/node/43872/psn-pdf
January 28, 2015 - Technology and error-prevention strategies: why are we
still overlooking the IV room?
January 28, 2015
ISMP Medication Safety Alert! Acute Care Edition. January 15, 2015;20:1-4.
https://psnet.ahrq.gov/issue/technology-and-error-prevention-strategies-why-are-we-still-overlooking-iv-
room
This newsletter article di…
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psnet.ahrq.gov/node/41421/psn-pdf
November 26, 2014 - "Learning by Doing"—resident perspectives on
developing competency in high-quality discharge care.
November 26, 2014
Greysen R, Schiliro D, Curry LA, et al. "Learning by doing"--resident perspectives on developing
competency in high-quality discharge care. J Gen Intern Med. 2012;27(9):1188-94. doi:10.1007/s11606-
…
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psnet.ahrq.gov/node/866257/psn-pdf
July 25, 2024 - Enhancing Surgical Team Communication: SOPS and
TeamSTEPPS in Action.
July 10, 2024
Agency for Healthcare Research and Quality. July 25, 2024.
https://psnet.ahrq.gov/issue/enhancing-surgical-team-communication-sops-and-teamstepps-action
Teamwork in the surgical suite is core to safe care but can be challenging to …
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psnet.ahrq.gov/node/50374/psn-pdf
September 25, 2019 - Explainable artificial intelligence for safe intraoperative
decision support.
September 25, 2019
Gordon L, Grantcharov T, Rudzicz F. Explainable Artificial Intelligence for Safe Intraoperative Decision
Support. JAMA Surg. 2019. doi:10.1001/jamasurg.2019.2821.
https://psnet.ahrq.gov/issue/explainable-artificial-int…
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psnet.ahrq.gov/node/40670/psn-pdf
August 03, 2011 - ED revamp: team approach to care reduces errors, boosts
patient and clinician satisfaction.
August 3, 2011
ED revamp: team approach to care reduces errors, boosts patient and clinician satisfaction. ED
management : the monthly update on emergency department management. 2011;23(7):78-80.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/47518/psn-pdf
January 23, 2019 - Evaluation of a measurement system to assess ICU team
performance.
January 23, 2019
Dietz AS, Salas E, Pronovost P, et al. Evaluation of a Measurement System to Assess ICU Team
Performance. Crit Care Med. 2018;46(12):1898-1905. doi:10.1097/CCM.0000000000003431.
https://psnet.ahrq.gov/issue/evaluation-measurement-s…
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psnet.ahrq.gov/node/43458/psn-pdf
August 27, 2014 - Validation of a teamwork perceptions measure to increase
patient safety.
August 27, 2014
Keebler JR, Dietz AS, Lazzara EH, et al. Validation of a teamwork perceptions measure to increase patient
safety. BMJ Qual Saf. 2014;23(9):718-26. doi:10.1136/bmjqs-2013-001942.
https://psnet.ahrq.gov/issue/validation-teamwork…
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psnet.ahrq.gov/node/42552/psn-pdf
January 14, 2014 - Interprofessional care in intensive care settings and the
factors that impact it: results from a scoping review of
ethnographic studies.
January 14, 2014
Paradis E, Leslie M, Gropper MA, et al. Interprofessional care in intensive care settings and the factors that
impact it: results from a scoping review of ethnog…
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psnet.ahrq.gov/node/44808/psn-pdf
March 16, 2016 - Interprofessional teamwork and team interventions in
chronic care: a systematic review.
March 16, 2016
Körner M, Bütof S, Müller C, et al. Interprofessional teamwork and team interventions in chronic care: A
systematic review. J Interprof Care. 2016;30(1):15-28. doi:10.3109/13561820.2015.1051616.
https://psnet.ahr…
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psnet.ahrq.gov/node/38425/psn-pdf
January 29, 2010 - Hospitalists as Emerging Leaders in Patient Safety:
lessons learned and future directions.
January 29, 2010
Flanders S, Kaufman SR, Saint S, et al. Hospitalists as emerging leaders in patient safety: lessons learned
and future directions. J Patient Saf. 2009;5(1):3-8. doi:10.1097/PTS.0b013e31819751f2.
https://psne…