U.S. Department of Health and Human Services
Agency for Healthcare Research and Quality: Advancing Excellence in Health Care
Sign up for a Free Account
Burger C, Eaton P, Hess K, et al. Patient Saf Qual Healthc. December 12, 2017.
Systems-based improvements are key to achieving patient safety. This article discusses the value of applying sociotechnical methods in all care environments to enhance practice and suggests that cognitive engineering can help uncover system flaws and design interventions.
2018 International Symposium on Human Factors and Ergonomics in Health Care.
Human Factors and Ergonomics Society. March 26–28, 2018; Marriott Copley Place, Boston, Massachusetts.
Patient Safety Certificate Program.
Armstrong Institute for Patient Safety and Quality. March 12-16, 2018; Constellation Energy Building, Baltimore, MD.
FDA Drug Safety Communication: FDA requires labeling changes for prescription opioid cough and cold medicines to limit their use to adults 18 years and older.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 11, 2018.
To err is human: use of simulation to enhance training and patient safety in anaesthesia.
Higham H, Baxendale B. Br J Anaesth. 2017;119(suppl 1):i106-i114.
Safe labeling practices to minimize medication errors in anesthesia: 5 case reports and review of the literature.
Prakash S, Mullick P, Kumar A, Pawar M. A A Case Rep. 2017 Nov 27; [Epub ahead of print].
Twelve tips for embedding human factors and ergonomics principles in healthcare education.
Vosper H, Hignett S, Bowie P. Med Teach. 2017 Nov 10; [Epub ahead of print].
Center for Health Care Human Factors.
Armstrong Institute for Patient Safety and Quality.
CVS taps a design legend to reinvent the prescription label. Next stop: the pharmacy.
Kuang C. Fast Company. October 4, 2017.
White paper on recommendation for systems-based practice competency.
Stalter AM, Phillips JM, Dolansky MA. QSEN Institute RN-BSN Task Force. J Nurs Care Qual. 2017;32:354-358.
Workarounds are routinely used by nurses—but are they ethical?
Berlinger N. Am J Nurs. 2017;117:53-55.
Creating a highly reliable neonatal intensive care unit through safer systems of care.
Panagos PG, Pearlman SA. Clin Perinatol. 2017;44:645-662.
Use of unit-based interventions to improve the quality of care for hospitalized medical patients: a national survey.
O'Leary KJ, Johnson JK, Manojlovich M, Astik GJ, Williams MV. Jt Comm J Qual Patient Saf. 2017;43:573–579.
Administering and monitoring high-alert medications in acute care.
Cajanding JMR. Nurs Stand. 2017;31:42-52.
Health and Social Care Ergonomics: Patient Safety in Practice.
Hignett S, Albolino S, Catchpole K, eds. Ergonomics. 2018;61:1-161.
Pictograms, units and dosing tools, and parent medication errors: a randomized study.
Yin HS, Parker RM, Sanders LM, et al. Pediatrics. 2017;140:e20163237.
Implementation science for ambulatory care safety: a novel method to develop context-sensitive interventions to reduce quality gaps in monitoring high-risk patients.
McDonald KM, Su G, Lisker S, Patterson ES, Sarkar U. Implement Sci. 2017;12:79.
Use of cascading A3s to drive systemwide improvement.
Winner LE, Burroughs TJ, Cady-Reh JA, et al. Jt Comm J Qual Patient Saf. 2017;43:422-428.
Human Factors Engineering
Patient, provider, and system factors contributing to patient safety events during medical and surgical hospitalizations for persons with serious mental illness.
McGinty EE, Thompson DA, Pronovost PJ, et al. J Nerv Ment Dis. 2017;205:495-501.
Workplace factors associated with burnout of family physicians.
Rassolian M, Peterson LE, Fang B, et al. JAMA Intern Med. 2017;177:1036-1038.
Changing the narratives for patient safety.
Pronovost PJ, Sutcliffe KM, Basu L, Dixon-Woods M. Bull World Health Organ. 2017;95:478-480.
Polypharmacy in the elderly—when good drugs lead to bad outcomes: a teachable moment.
Carroll C, Hassanin A. JAMA Intern Med. 2017;177:871.
Inpatient Notes: human factors engineering and inpatient care—new ways to solve old problems.
Clack L, Sax H. Ann Intern Med. 2017;166:HO2-HO3.
Repeat prescribing of medications: a system-centred risk management model for primary care organisations.
Price J, Man SL, Bartlett S, Taylor K, Dinwoodie M, Bowie P. J Eval Clin Pract. 2017;23:779-796.
The dichotomy of the application of a systems approach in UK healthcare the challenges and priorities for implementation.
Pickup L, Lang A, Atkinson S, Sharples S. Ergonomics. 2018;61:15-25.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364