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psnet.ahrq.gov/node/43666/psn-pdf
March 14, 2016 - Interdisciplinary Quality Improvement Conference: using
a revised morbidity and mortality format to focus on
systems-based patient safety issues in a VA hospital:
design and outcomes.
March 14, 2016
Gerstein WH, Ledford J, Cooper J, et al. Interdisciplinary Quality Improvement Conference: using a revised
morbidit…
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psnet.ahrq.gov/node/46993/psn-pdf
July 18, 2018 - The nature, magnitude, and reporting compliance of
device-related events for intravenous patient-controlled
analgesia in the FDA Manufacturer and User Facility
Device Experience (MAUDE) database.
July 18, 2018
Lawal OD, Mohanty M, Elder H, et al. The nature, magnitude, and reporting compliance of device-related
e…
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psnet.ahrq.gov/node/867234/psn-pdf
December 04, 2024 - Survey results reveal tubing misconnections are common
and underreported—Parts I and II.
December 4, 2024
Survey results reveal tubing misconnections are common and underreported—Parts I and II. ISMP
Medication Safety Alert! Acute Care. October 31, 2024;29(22 & 23):1-5;1-4.
https://psnet.ahrq.gov/issue/survey-resu…
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psnet.ahrq.gov/node/838131/psn-pdf
January 01, 2023 - What I wish I’d known: how experienced physician
managers diagnose, treat and prevent disruptive
behaviour.
September 21, 2022
Goodwin C, Haas S, Berry WR. What I wish I’d known: how experienced physician managers diagnose,
treat and prevent disruptive behaviour. BMJ Lead. 2023;7(2):128-132. doi:10.1136/leader-202…
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psnet.ahrq.gov/node/46346/psn-pdf
October 29, 2017 - Root cause analysis of ICU adverse events in the
Veterans Health Administration.
October 29, 2017
Corwin GS, Mills PD, Shanawani H, et al. Root Cause Analysis of ICU Adverse Events in the Veterans
Health Administration. Jt Comm J Qual Patient Saf. 2017;43(11):580-590. doi:10.1016/j.jcjq.2017.04.009.
https://psnet.…
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psnet.ahrq.gov/node/37984/psn-pdf
August 13, 2008 - Planning and implementing a systems-based patient
safety curriculum in medical education.
August 13, 2008
Thompson DA, Cowan J, Holzmueller CG, et al. Planning and implementing a systems-based patient
safety curriculum in medical education. Am J Med Qual. 2008;23(4):271-8.
doi:10.1177/1062860608317763.
https://ps…
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psnet.ahrq.gov/node/866107/psn-pdf
June 12, 2024 - Hospital inpatient nutrition service errors and patient
safety interventions: a scoping review.
June 12, 2024
Austria D, McConnell C, Pope C. Hospital inpatient nutrition service errors and patient safety interventions:
a scoping review. J Patient Saf. 2024;20(4):272-278. doi:10.1097/pts.0000000000001223.
https://…
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psnet.ahrq.gov/node/854251/psn-pdf
October 04, 2023 - A scoping review exploring the confidence of healthcare
professionals in assessing all skin tones.
October 4, 2023
Harrison J. A scoping review exploring the confidence of healthcare professionals in assessing all skin
tones. Br Paramed J. 2023;8(2):18-28. doi:10.29045/14784726.2023.9.8.2.18.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/37903/psn-pdf
May 09, 2013 - Safe Surgery.
May 9, 2013
World Health Organization.
https://psnet.ahrq.gov/issue/safe-surgery-saves-lives-second-global-patient-safety-challenge
This initiative provides a surgical safety checklist and related educational and training materials building on
the Second Global Patient Safety Challenge vision to enco…
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psnet.ahrq.gov/node/764405/psn-pdf
March 02, 2022 - Evaluation of communication and safety behaviors during
hospital-wide code response simulation.
March 2, 2022
Ren DM, Abrams A, Banigan M, et al. Evaluation of communication and safety behaviors during hospital-
wide code response simulation. Simul Healthc. 2022;17(1):e45-e50. doi:10.1097/sih.0000000000000575.
htt…
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psnet.ahrq.gov/node/40355/psn-pdf
July 09, 2012 - The Silent Treatment: Why Safety Tools and Checklists
Aren't Enough to Save Lives.
July 9, 2012
Maxfield D, Grenny J, Lavandero R, et al. Provo, UT: VitalSmarts; 2011.
https://psnet.ahrq.gov/issue/silent-treatment-why-safety-tools-and-checklists-arent-enough-save-lives
Silence Kills was a 2005 report that highligh…
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psnet.ahrq.gov/node/36644/psn-pdf
July 10, 2008 - Reporting and disclosing medical errors: pediatricians'
attitudes and behaviors.
July 10, 2008
Garbutt J, Brownstein DR, Klein EJ, et al. Reporting and disclosing medical errors: pediatricians' attitudes
and behaviors. Arch Pediatr Adolesc Med. 2007;161(2):179-85.
https://psnet.ahrq.gov/issue/reporting-and-disclos…
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psnet.ahrq.gov/node/47323/psn-pdf
September 26, 2018 - About politeness, face, and feedback: exploring resident
and faculty perceptions of how institutional feedback
culture influences feedback practices.
September 26, 2018
Ramani S, Könings KD, Mann K, et al. About Politeness, Face, and Feedback: Exploring Resident and
Faculty Perceptions of How Institutional Feedbac…
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psnet.ahrq.gov/node/45594/psn-pdf
December 19, 2017 - Teaching quality improvement and patient safety in
residency education: strategies for meaningful resident
quality and safety initiatives.
December 19, 2017
Morrison RJ, Bowe SN, Brenner MJ. Teaching Quality Improvement and Patient Safety in Residency
Education: Strategies for Meaningful Resident Quality and Safet…
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psnet.ahrq.gov/node/60873/psn-pdf
September 02, 2020 - What has been the impact of Covid-19 on safety culture?
A case study from a large metropolitan healthcare trust.
September 2, 2020
Denning M, Goh ET, Scott A, et al. What has been the impact of Covid-19 on safety culture? A case study
from a large metropolitan healthcare trust. Int J Environ Res Public Health. 2020…
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psnet.ahrq.gov/node/862154/psn-pdf
June 18, 2020 - Listening to women: recommendations from women of
color to improve experiences in pregnancy and birth care.
June 18, 2020
Altman MR, McLemore MR, Oseguera T, et al. Listening to women: recommendations from women of color
to improve experiences in pregnancy and birth care. J Midwifery Womens Health. 2020;65(4):466-4…
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psnet.ahrq.gov/sites/default/files/2021-09/Battle%20buddies%20tip%20sheet%20(1).pdf
January 01, 2021 - I have a Battle Buddy – Now What?
Battle Buddies are not just for battle.
It’s critical to start connecting with your Battle Buddy now - before
things get really stressful.
It’s like training prior to a marathon.
Brief conversations now will strengthen your individual and team
resilience and ensure o…
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psnet.ahrq.gov/node/836773/psn-pdf
March 23, 2022 - Association between operative autonomy of surgical
residents and patient outcomes.
March 23, 2022
Oliver JB, Kunac A, McFarlane JL, et al. Association between operative autonomy of surgical residents and
patient outcomes. JAMA Surg. 2022;157(3):211-219. doi:10.1001/jamasurg.2021.6444.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/73666/psn-pdf
September 01, 2021 - Implementation of participatory organizational change in
long term care to improve safety.
September 1, 2021
Van Eerd D, D'Elia T, Ferron EM, et al. Implementation of participatory organizational change in long term
care to improve safety. J Safety Res. 2021;78:9-18. doi:10.1016/j.jsr.2021.05.002.
https://psnet.ah…
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psnet.ahrq.gov/node/837148/psn-pdf
May 18, 2022 - Assessing quality of older persons' emergency
transitions between long-term and acute care settings: a
proof-of-concept study.
May 18, 2022
Tate K, McLane P, Reid C, et al. Assessing quality of older persons’ emergency transitions between long-
term and acute care settings: a proof-of-concept study. BMJ Open Qual.…