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psnet.ahrq.gov/node/34697/psn-pdf
December 08, 2010 - Sentinel events. In memory of Ben—a case study.
December 8, 2010
Haas D. Sentinel events. In memory of Ben--a case study. Jt Comm Perspect. 1997;17(2):12-5.
https://psnet.ahrq.gov/issue/sentinel-events-memory-ben-case-study
Written from the perspective of a risk manager, the author tells the story of a medication a…
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psnet.ahrq.gov/issue/evolution-patient-safety
August 22, 2012 - Audiovisual
Audiovisual Presentation
Published August 22, 2012
The evolution of patient safety.
Topics
Approach to Improving Safety
Human Factors Engineering
Education and Training
Resource Type
Audiovisual Presentation
Audiovisual
Setting of Care
Hospitals
Clinical Area
Medicine
Target Audience
Health …
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psnet.ahrq.gov/node/863214/psn-pdf
February 28, 2024 - Appropriate use of medical interpreters in the breast
imaging clinic.
February 28, 2024
Feliciano-Rivera YZ, Yepes MM, Sanchez P, et al. Appropriate use of medical interpreters in the breast
imaging clinic. J Breast Imaging. 2024;27(3):296-303. doi:10.1093/jbi/wbad109.
https://psnet.ahrq.gov/issue/appropriate-use-…
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psnet.ahrq.gov/node/865813/psn-pdf
May 08, 2024 - Quality framework for remote antenatal care: qualitative
study with women, healthcare professionals and system-
level stakeholders.
May 8, 2024
Hinton L, Dakin FH, Kuberska K, et al. Quality framework for remote antenatal care: qualitative study with
women, healthcare professionals and system-level stakeholders. B…
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psnet.ahrq.gov/node/865875/psn-pdf
May 15, 2024 - Digital health interventions and patient safety in
abdominal surgery: a systematic review and meta-
analysis.
May 15, 2024
Grygorian A, Montano D, Shojaa M, et al. Digital health interventions and patient safety in abdominal
surgery: a systematic review and meta-analysis. JAMA Netw Open. 2024;7(4):e248555.
doi:10…
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psnet.ahrq.gov/issue/improving-diagnosis-health-care-implementation-workshop
August 19, 2020 - Audiovisual Presentation
Improving Diagnosis in Health Care: An Implementation Workshop.
Citation Text:
National Academies of Sciences, Engineering, and Medicine; IOM.
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psnet.ahrq.gov/node/60254/psn-pdf
January 01, 2022 - Do patients and relatives have different dispositions when
challenging healthcare professionals about patient
safety? Results before and after an educational program.
April 22, 2020
Rodrigo-Rincon I, Irigoyen-Aristorena I, Tirapu-Leon B, et al. Do patients and relatives have different
dispositions when challenging…
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psnet.ahrq.gov/node/50802/psn-pdf
January 15, 2020 - Use of error management theory to quantify and
characterize residents' error recovery strategies.
January 15, 2020
Pugh CM, Law KE, Cohen ER, et al. Use of error management theory to quantify and characterize
residents’ error recovery strategies. Am J Surg. 2020;219(2):214-220. doi:10.1016/j.amjsurg.2019.11.013.
h…
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psnet.ahrq.gov/node/74862/psn-pdf
February 23, 2022 - Use of pediatric injectable medicines guidelines and
associated medication administration errors: a human
reliability analysis.
February 23, 2022
Jones MD, Clarke J, Feather C, et al. Use of pediatric injectable medicines guidelines and associated
medication administration errors: a human reliability analysis. Ann…
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psnet.ahrq.gov/node/60916/psn-pdf
September 17, 2020 - Impact of professional interpreters on outcomes for
hospitalized children from migrant and refugee families
with limited English proficiency: a systematic review.
September 17, 2020
Boylen S, Cherian S, Gill FJ, et al. Impact of professional interpreters on outcomes for hospitalized children
from migrant and refug…
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psnet.ahrq.gov/node/73567/psn-pdf
August 04, 2021 - Pharmacist-led educational interventions provided to
healthcare providers to reduce medication errors: a
systematic review and meta-analysis.
August 4, 2021
Jaam M, Naseralallah LM, Hussain TA, et al. Pharmacist-led educational interventions provided to
healthcare providers to reduce medication errors: a systemati…
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psnet.ahrq.gov/node/838245/psn-pdf
January 01, 2023 - A novel study of situational awareness among out-of-
hospital providers during an online clinical simulation.
October 5, 2022
Hunter J, Porter M, Williams B. A novel study of situational awareness among out-of-hospital providers
during an online clinical simulation. Australas Emerg Care. 2023;26(1):96-103.
doi:10.…
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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/837896/psn-pdf
January 01, 2023 - Helping healthcare teams to debrief effectively:
associations of debriefers' actions and participants'
reflections during team debriefings.
August 24, 2022
Kolbe M, Grande B, Lehmann-Willenbrock N, et al. Helping healthcare teams to debrief effectively:
associations of debriefers’ actions and participants’ reflect…
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psnet.ahrq.gov/node/50654/psn-pdf
November 13, 2019 - Exploring stakeholder perceptions around
implementation of the Operating Room Black Box for
patient safety research: a qualitative study using the
theoretical domains framework.
November 13, 2019
Etherington N, Usama A, Patey AM, et al. Exploring stakeholder perceptions around implementation of the
Operating Room…
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psnet.ahrq.gov/node/47566/psn-pdf
January 30, 2019 - Important factors for effective patient safety governance
auditing: a questionnaire survey.
January 30, 2019
van Gelderen SC, Zegers M, Robben PB, et al. Important factors for effective patient safety governance
auditing: a questionnaire survey. BMC Health Serv Res. 2018;18(1):798. doi:10.1186/s12913-018-3577-9.
h…
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psnet.ahrq.gov/node/50866/psn-pdf
February 05, 2020 - Effectiveness of acute care remote triage systems: a
systematic review.
February 5, 2020
Boggan JC, Shoup JP, Whited JD, et al. Effectiveness of acute care remote triage systems: a systematic
review. J Gen Intern Med. 2020;35(7):2136-2145. doi:10.1007/s11606-019-05585-4.
https://psnet.ahrq.gov/issue/effectiveness-…
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psnet.ahrq.gov/node/43285/psn-pdf
July 16, 2014 - Outcomes of a quality improvement project for educating
nurses on medication administration and errors in
nursing homes.
July 16, 2014
Tenhunen ML, Tanner EK, Dahlen R. Outcomes of a quality improvement project for educating nurses on
medication administration and errors in nursing homes. J Contin Educ Nurs. 2014;…
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psnet.ahrq.gov/issue/pressure-causing-drug-errors
April 19, 2017 - Audiovisual
Is pressure causing drug errors?
Citation Text:
Meyer T.
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June 3, 2015
Meyer T.
Reporting on how production pressure…
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psnet.ahrq.gov/issue/possible-dose-counter-errors-asmanex-twisthaler
March 11, 2015 - Government Resource
Possible dose-counter errors with the Asmanex Twisthaler.
Citation Text:
Food and Drug Administration; FDA
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