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psnet.ahrq.gov/node/47219/psn-pdf
July 25, 2018 - Preparing clinicians for transitioning patients across care
settings and into the home through simulation.
July 25, 2018
Molloy MA, Cary MP, Brennan-Cook J, et al. Preparing Clinicians for Transitioning Patients Across Care
Settings and Into the Home Through Simulation. Home Healthc Now. 2018;36(4):225-231.
doi:10…
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psnet.ahrq.gov/node/849135/psn-pdf
May 17, 2023 - Quality and Safety Considerations in Intensity Modulated
Radiation Therapy: An ASTRO Safety White Paper
Update.
May 17, 2023
Moran JM, Bazan JG, Dawes SL, et al. Quality and Safety Considerations in Intensity Modulated Radiation
Therapy: An ASTRO Safety White Paper Update. Pract Radiat Oncol. 2023;13(3):203-216.
…
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psnet.ahrq.gov/node/866648/psn-pdf
September 04, 2024 - ACOG Committee Statement No. 10: Racial and Ethnic
Inequities in Obstetrics and Gynecology.
September 4, 2024
ACOG Committee Statement No. 10: Racial and Ethnic Inequities in Obstetrics and Gynecology. Obstet
Gynecol. 2024;144(3):e62-e74. doi:10.1097/aog.0000000000005678.
https://psnet.ahrq.gov/issue/acog-committe…
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psnet.ahrq.gov/node/43038/psn-pdf
March 05, 2014 - Missed it.
March 5, 2014
Green MJ, Rieck R. Missed it. Ann Intern Med. 2013;158(5 Pt 1):357-61. doi:10.7326/0003-4819-158-5-
201303050-00013.
https://psnet.ahrq.gov/issue/missed-it-0
This piece uses a graphic novel format to depict a story of a diagnostic error that resulted in a patient’s
death. The attention-gr…
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psnet.ahrq.gov/node/844783/psn-pdf
September 04, 2019 - A lethal hidden curriculum—death of a medical student
from opioid use disorder.
September 4, 2019
Lucey CR, Jones L, Eastburn A. A Lethal Hidden Curriculum - Death of a Medical Student from Opioid Use
Disorder. N Engl J Med. 2019;381(9):793-795. doi:10.1056/NEJMp1901537.
https://psnet.ahrq.gov/issue/lethal-hidden-…
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psnet.ahrq.gov/node/46926/psn-pdf
March 07, 2018 - A comprehensive program to reduce rates of hospital-
acquired pressure ulcers in a system of community
hospitals.
March 7, 2018
Englebright J, Westcott R, McManus K, et al. A Comprehensive Program to Reduce Rates of Hospital-
Acquired Pressure Ulcers in a System of Community Hospitals. J Patient Saf. 2018;14(1):54…
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psnet.ahrq.gov/node/44780/psn-pdf
May 09, 2017 - Improving anesthesiologists' ability to speak up in the
operating room: a randomized controlled experiment of a
simulation-based intervention and a qualitative analysis
of hurdles and enablers.
May 9, 2017
Raemer DB, Kolbe M, Minehart RD, et al. Improving Anesthesiologists’ Ability to Speak Up in the Operating
Ro…
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psnet.ahrq.gov/node/47975/psn-pdf
May 29, 2019 - Surgical Innovation, New Techniques and Technologies:
A Guide to Good Practice.
May 29, 2019
London, UK: Royal College of Surgeons of England; 2019.
https://psnet.ahrq.gov/issue/surgical-innovation-new-techniques-and-technologies-guide-good-practice
Introducing innovations in practice involves taking calculated ri…
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psnet.ahrq.gov/node/43637/psn-pdf
April 25, 2016 - Lost in translation? Addressing barriers in the application
of industrial process improvement methodologies to
health care.
April 25, 2016
Gray D, Johnson KD, Watts B. Lost In Translation? Addressing Barriers in the Application of Industrial
Process Improvement Methodologies to Health Care. Jt Comm J Qual Patient …
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psnet.ahrq.gov/node/45670/psn-pdf
November 16, 2016 - Not thinking clearly? Play a game, seriously!
November 16, 2016
Mohan D, Schell J, Angus DC. Not Thinking Clearly? Play a Game, Seriously!. JAMA. 2016;316(18):1867-
1868. doi:10.1001/jama.2016.14174.
https://psnet.ahrq.gov/issue/not-thinking-clearly-play-game-seriously
Heuristics enable experts to build off their …
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psnet.ahrq.gov/node/60600/psn-pdf
June 17, 2020 - Reasons for drug administration problems and perceived
needs for assistance of patients, family caregivers, and
nurses: a qualitative study.
June 17, 2020
Lampert A, Haefeli WE, Seidling HM. Reasons for drug administration problems and perceived needs for
assistance of patients, family caregivers, and nurses: a qu…
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psnet.ahrq.gov/node/34700/psn-pdf
January 04, 2017 - Reducing adverse drug events: lessons from a
breakthrough series collaborative.
January 4, 2017
Leape L, Kabcenell AI, Gandhi TK, et al. Reducing adverse drug events: lessons from a breakthrough
series collaborative. Jt Comm J Qual Improv. 2000;26(6):321-31.
https://psnet.ahrq.gov/issue/reducing-adverse-drug-event…
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psnet.ahrq.gov/node/866355/psn-pdf
July 24, 2024 - Frequency and preventability of adverse drug events in
the outpatient setting.
July 24, 2024
Wasserman RL, Edrees HH, Amato MG, et al. Frequency and preventability of adverse drug events in the
outpatient setting. BMJ Qual Saf. 2024;Epub Jul 9. doi:10.1136/bmjqs-2024-017098.
https://psnet.ahrq.gov/issue/frequency-…
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psnet.ahrq.gov/node/60621/psn-pdf
June 24, 2020 - Design and implementation of the infection prevention
program into risk management: managing high level
disinfection and sterilization in the outpatient setting.
June 24, 2020
Sweet W, Snyder D, Raymond M. Design and implementation of the infection prevention program into risk
management: Managing high level disin…
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psnet.ahrq.gov/node/50688/psn-pdf
November 20, 2019 - Roles and role ambiguity in patient- and caregiver-
performed outpatient parenteral antimicrobial therapy.
November 20, 2019
Keller SC, Cosgrove SE, Arbaje AI, et al. Roles and Role Ambiguity in Patient- and Caregiver-Performed
Outpatient Parenteral Antimicrobial Therapy. Jt Comm J Qual Patient Saf. 2019;45(11):763…
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psnet.ahrq.gov/node/837510/psn-pdf
June 22, 2022 - In situ simulation for adoption of new technology to
improve sepsis care in rural emergency departments.
June 22, 2022
Powell ES, Bond WF, Barker LT, et al. In situ simulation for adoption of new technology to improve sepsis
care in rural emergency departments. J Patient Saf. 2022;18(4):302-309.
doi:10.1097/pts.00…
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psnet.ahrq.gov/node/48011/psn-pdf
May 29, 2019 - Is it time for safeguards in the adoption of robotic
surgery?
May 29, 2019
Sheetz KH, Dimick JB. Is It Time for Safeguards in the Adoption of Robotic Surgery? JAMA.
2019;321(20):1971-1972. doi:10.1001/jama.2019.3736.
https://psnet.ahrq.gov/issue/it-time-safeguards-adoption-robotic-surgery
The FDA recently raised …
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psnet.ahrq.gov/node/73462/psn-pdf
July 07, 2021 - Root cause analysis to identify contributing factors for
the development of hospital acquired pressure injuries.
July 7, 2021
Abela G. Root cause analysis to identify contributing factors for the development of hospital acquired
pressure injuries. J Tissue Viability. 2021;30(3):339-345. doi:10.1016/j.jtv.2021.04.00…
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psnet.ahrq.gov/node/45815/psn-pdf
January 25, 2017 - Handoffs: transitions of care for children in the
emergency department.
January 25, 2017
American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of
Emergency Physicians Pediatric Emergency Medicine Committee, Emergency Nurses Association
Pediatric Committee. Pediatrics. 2016;138:…
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psnet.ahrq.gov/node/40563/psn-pdf
September 09, 2011 - Shedding light on the dark side of doctor–patient
interactions: verbal and nonverbal messages physicians
communicate during error disclosures.
September 9, 2011
Hannawa AF. Shedding light on the dark side of doctor-patient interactions: verbal and nonverbal
messages physicians communicate during error disclosures.…