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psnet.ahrq.gov/node/43955/psn-pdf
December 04, 2016 - For Colorado mom, story of daughter's hospital death is
key to others' safety.
December 4, 2016
Daley J. Colorado Public Radio. February 17, 2015.
https://psnet.ahrq.gov/issue/colorado-mom-story-daughters-hospital-death-key-others-safety
Patient and family stories of harm are increasingly promoted as a strategy to…
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January 15, 2014 - Sign-out snapshot: cross-sectional evaluation of written
sign-outs among specialties.
January 15, 2014
Schoenfeld AR, Al-Damluji MS, Horwitz LI. Sign-out snapshot: cross-sectional evaluation of written sign-
outs among specialties. BMJ Qual Saf. 2014;23(1):66-72. doi:10.1136/bmjqs-2013-002164.
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psnet.ahrq.gov/node/45015/psn-pdf
July 18, 2016 - Interhospital transfer handoff practices among US tertiary
care centers: a descriptive survey.
July 18, 2016
Herrigel DJ, Carroll M, Fanning C, et al. Interhospital transfer handoff practices among US tertiary care
centers: A descriptive survey. J Hosp Med. 2016;11(6):413-7. doi:10.1002/jhm.2577.
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June 18, 2021 - Preventing violence in the health care setting.
June 18, 2021
Preventing violence in the health care setting. Sentinel Event Alert. 2010;(45):1-3.
https://psnet.ahrq.gov/issue/preventing-violence-health-care-setting
Revised June 2021. The Joint Commission issues sentinel event alerts to highlight areas of high risk…
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psnet.ahrq.gov/node/72628/psn-pdf
January 13, 2021 - Awareness of human factors in the operating theatres
during the COVID-19 pandemic.
January 13, 2021
Britton CR, Hayman G, Stroud N. Awareness of Human Factors in the operating theatres during the
COVID-19 pandemic. J Perioper Pract. 2021;31(1-2):44-50. doi:10.1177/1750458920978858.
https://psnet.ahrq.gov/issue/awa…
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psnet.ahrq.gov/node/43048/psn-pdf
April 02, 2014 - Building a Culture of Candour: a Review of the Threshold
for the Duty of Candour and of the Incentives for Care
Organisations to Be Candid.
April 2, 2014
Dalton D, Williams N. London, UK: The Royal College of Surgeons of England; March 2014.
https://psnet.ahrq.gov/issue/building-culture-candour-review-thresh…
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psnet.ahrq.gov/node/35510/psn-pdf
February 19, 2010 - Simulation study of rested versus sleep-deprived
anesthesiologists.
February 19, 2010
Howard SK, Gaba DM, Smith B, et al. Simulation study of rested versus sleep-deprived anesthesiologists.
Anesthesiology. 2003;98(6):1345-1355. doi:10.1097/00000542-200306000-00008.
https://psnet.ahrq.gov/issue/simulation-study-res…
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psnet.ahrq.gov/node/43404/psn-pdf
August 06, 2014 - 'Even now it makes me angry': health care students'
professionalism dilemma narratives.
August 6, 2014
Monrouxe L, Rees CE, Endacott R, et al. 'Even now it makes me angry': health care students'
professionalism dilemma narratives. Med Educ. 2014;48(5):502-17. doi:10.1111/medu.12377.
https://psnet.ahrq.gov/issue/ev…
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psnet.ahrq.gov/node/73178/psn-pdf
April 28, 2021 - Risk perception on the labour ward: a mixed methods
study.
April 28, 2021
McCarthy C, Meaney S, Rochford M, et al. Risk perception on the labour ward: a mixed methods study. J
Patient Saf Risk Manag. 2021;26(2):56-63. doi:10.1177/25160435211002428.
https://psnet.ahrq.gov/issue/risk-perception-labour-ward-mixed-met…
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digital.ahrq.gov/principal-investigator/thompson-hale-m
January 01, 2023 - Thompson, Hale M.
A Machine Learning Health System to Integrate Care for Substance Misuse and HIV Treatment and Prevention Among Hospitalized Patients - Final Report
Citation
Held M., Thompson H. A Machine Learning Health System to Integrate Care for Substance Misuse and HIV T…
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digital.ahrq.gov/principal-investigator/held-philip
January 01, 2023 - Held, Philip
A Machine Learning Health System to Integrate Care for Substance Misuse and HIV Treatment and Prevention Among Hospitalized Patients - Final Report
Citation
Held M., Thompson H. A Machine Learning Health System to Integrate Care for Substance Misuse and HIV Treatm…
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psnet.ahrq.gov/node/60032/psn-pdf
March 11, 2020 - Medical teamwork and the evolution of safety science: a
critical review.
March 11, 2020
Neuhaus C, Lutnæs DE, Bergström J. Medical teamwork and the evolution of safety science: a critical
review. Cogn Technol Work. 2020;22(1):13-27. doi:10.1007/s10111-019-00545-8.
https://psnet.ahrq.gov/issue/medical-teamwork-and-…
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psnet.ahrq.gov/node/46866/psn-pdf
May 23, 2018 - Improving maternal safety at scale with the mentor model
of collaborative improvement.
May 23, 2018
Main EK, Dhurjati R, Cape V, et al. Improving Maternal Safety at Scale with the Mentor Model of
Collaborative Improvement. Jt Comm J Qual Patient Saf. 2018;44(5):250-259.
doi:10.1016/j.jcjq.2017.11.005.
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July 24, 2019 - Evidence Brief: Implementation of High Reliability
Organization Principles.
July 24, 2019
Veazie S, Peterson K, Bourne D. Washington DC: United States Department of Veterans Affairs;
May 2019.
https://psnet.ahrq.gov/issue/evidence-brief-implementation-high-reliability-organization-principles
This brief evalu…
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August 09, 2023 - Guidelines on Human Factors in Critical Situations 2023.
August 9, 2023
Bijok B, Jaulin F, Picard J, et al. Guidelines on human factors in critical situations 2023. Anaesth Crit Care
Pain Med. 2023;42(4):101262. doi:10.1016/j.accpm.2023.101262.
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psnet.ahrq.gov/node/46271/psn-pdf
January 30, 2018 - Debiasing health-related judgments and decision making:
a systematic review.
January 30, 2018
Ludolph R, Schulz PJ. Debiasing Health-Related Judgments and Decision Making: A Systematic Review.
Med Decis Making. 2018;38(1):3-13. doi:10.1177/0272989X17716672.
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psnet.ahrq.gov/node/47241/psn-pdf
October 10, 2018 - Impact of high-reliability education on adverse event
reporting by registered nurses.
October 10, 2018
McFarland DM, Doucette JN. Impact of High-Reliability Education on Adverse Event Reporting by
Registered Nurses. J Nurs Care Qual. 2018;33(3):285-290. doi:10.1097/NCQ.0000000000000291.
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www.ahrq.gov/hai/tools/mvp/modules/sustainability/premortem-scorecard-fac-guide.html
February 01, 2017 - Ask:
How much of the staff has been trained in the Science of Safety?
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psnet.ahrq.gov/node/848107/psn-pdf
April 26, 2023 - Insight cannot be trained or taught but could be cultivated through both individual education and
intentional
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psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
January 31, 2024 - Insight cannot be trained or taught but could be cultivated through both individual education and intentional