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psnet.ahrq.gov/issue/use-cascading-a3s-drive-systemwide-improvement
January 29, 2015 - Commentary
Use of cascading A3s to drive systemwide improvement.
Citation Text:
Winner LE, Burroughs TJ, Cady-Reh JA, et al. Use of Cascading A3s to Drive Systemwide Improvement. Jt Comm J Qual Patient Saf. 2017;43(8):422-428. doi:10.1016/j.jcjq.2017.03.011.
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psnet.ahrq.gov/issue/health-care-associated-infections-hospitals-continuing-leadership-needed-hhs-prioritize
September 06, 2016 - Congressional Testimony
Health-Care–Associated Infections in Hospitals: Continuing Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on These Infections.
Citation Text:
Health-Care–Associated Infections in Hospitals: Continuing Leadership Needed from HHS to…
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psnet.ahrq.gov/node/854379/psn-pdf
October 11, 2023 - The limits of psychological safety: nonlinear relationships
with performance.
October 11, 2023
Eldor L, Hodor M, Cappelli P. The limits of psychological safety: nonlinear relationships with performance.
Org Behav Human Decision Proc. 2023;177:104255. doi:10.1016/j.obhdp.2023.104255.
https://psnet.ahrq.gov/issue/li…
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - surgical site, rather
than relying on external agencies or systems, so all providers of care are held accountable
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psnet.ahrq.gov/node/851462/psn-pdf
July 19, 2023 - Broken Trust: Making Patient Safety More than Just a
Promise.
July 19, 2023
Manchester, UK: Parliamentary and Health Service Ombudsman; June 2023. ISBN: 9781528642446.
https://psnet.ahrq.gov/issue/broken-trust-making-patient-safety-more-just-promise
Lack of accountability for systemic contributions to failure degr…
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psnet.ahrq.gov/node/47378/psn-pdf
February 22, 2019 - Taking the blame: appropriate responses to medical error.
February 22, 2019
Tigard DW. Taking the blame: appropriate responses to medical error. J Med Ethics. 2019;45(2):101-105.
doi:10.1136/medethics-2017-104687.
https://psnet.ahrq.gov/issue/taking-blame-appropriate-responses-medical-error
Balancing between expli…
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psnet.ahrq.gov/node/836762/psn-pdf
March 16, 2022 - Physician liability in the age of data reliance and errors.
March 16, 2022
Montesantos L. Ann Health Law Life Sci. 2022;31(Spring):179-215.
https://psnet.ahrq.gov/issue/physician-liability-age-data-reliance-and-errors
Health information technologies (HIT) and advanced learning systems, if poorly designed, used,
ma…
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psnet.ahrq.gov/issue/restorative-just-culture-exploration-enabling-conditions-successful-implementation
February 08, 2023 - Study
Restorative just culture: an exploration of the enabling conditions for successful implementation.
Citation Text:
Boskeljon-Horst L, Steinmetz V, Dekker SWA. Restorative just culture: an exploration of the enabling conditions for successful implementation. Healthcare (Basel). 2024;…
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psnet.ahrq.gov/issue/actions-needed-improve-newly-enrolled-veterans-access-primary-care
September 07, 2016 - Government Resource
Actions Needed to Improve Newly Enrolled Veterans' Access to Primary Care.
Citation Text:
Actions Needed to Improve Newly Enrolled Veterans' Access to Primary Care. Washington, DC: United States Government Accountability Office; March 18, 2016. Publication GAO-16-328.…
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psnet.ahrq.gov/issue/complementary-approach-promoting-professionalism-identifying-measuring-and-addressing
June 27, 2018 - Study
Classic
A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors.
Citation Text:
Hickson GB, Pichert JW, Webb LE, et al. A complementary approach to promoting professionalism: identifying, mea…
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psnet.ahrq.gov/issue/whatever-you-cut-i-can-fix-it-clinical-supervisors-interview-accounts-allowing-trainee
November 24, 2021 - Study
'Whatever you cut, I can fix it': clinical supervisors' interview accounts of allowing trainee failure while guarding patient safety.
Citation Text:
Klasen JM, Driessen E, Teunissen PW, et al. ‘Whatever you cut, I can fix it’: clinical supervisors’ interview accounts of allowing t…
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psnet.ahrq.gov/issue/medicares-hospital-acquired-condition-reduction-program-and-community-diversity-united-states
May 13, 2020 - Study
Medicare's Hospital-Acquired Condition Reduction Program and community diversity in the United States: the need to account for racial and ethnic segregation.
Citation Text:
Hamadi H, Tafili A, Apatu E, et al. Medicare' Hospital-Acquired Condition Reduction Program and Community Div…
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psnet.ahrq.gov/node/867521/psn-pdf
April 01, 2024 - Patient safety trends in 2023: an analysis of 287,997
serious events and incidents from the nation’s largest
event reporting database.
April 1, 2024
Kepner S, Jones RM. Patient safety trends in 2023: an analysis of 287,997 serious events and incidents
from the nation’s largest event reporting database. Patient Saf…
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psnet.ahrq.gov/node/73245/psn-pdf
May 12, 2021 - Just culture: the foundation of staff safety in the
perioperative environment.
May 12, 2021
Fencl JL, Willoughby C, Jackson K. Just culture: the foundation of staff safety in the perioperative
environment. AORN J. 2021;113(4):329-336. doi:10.1002/aorn.13352.
https://psnet.ahrq.gov/issue/just-culture-foundation-sta…
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psnet.ahrq.gov/issue/conversation-among-stakeholders-medical-malpractice
January 11, 2023 - Meeting/Conference Proceedings
A Conversation Among Stakeholders on Medical Malpractice.
Citation Text:
A Conversation Among Stakeholders on Medical Malpractice. Collaborative for Accountability and Improvement. April 26, 2022.
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psnet.ahrq.gov/issue/creating-communication-coaching-structure-and-support-your-crp-program
January 25, 2023 - Webinar
Creating a Communication Coaching Structure and Support for your CRP Program.
Citation Text:
Creating a Communication Coaching Structure and Support for your CRP Program. Collaborative for Accountability and Improvement. September 15, 2022.
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psnet.ahrq.gov/issue/what-do-you-do-if-you-think-you-have-been-harmed-your-healthcare
January 25, 2023 - Fact Sheet/FAQs
What Do You Do If You Think You Have Been Harmed By Your Healthcare.
Citation Text:
What Do You Do If You Think You Have Been Harmed By Your Healthcare. Seattle, WA: Collaborative for Accountability and Improvement; 2023.
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psnet.ahrq.gov/node/856634/psn-pdf
January 01, 2024 - Perspectives on perioperative team-based morbidity and
mortality conferences: a mixed-methods study.
November 29, 2023
Samost-Williams A, Rosen R, Cummins E, et al. Perspectives on Perioperative Team-Based Morbidity and
Mortality Conferences: A Mixed Methods Study. Jt Comm J Qual Patient Saf. 2024;50(2):139-148.
d…
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psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
August 28, 2024 - Each team is formally chartered by an executive leadership team accountable for operationalizing the … This work is then formally reported to and acted on by the accountable leadership team.
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psnet.ahrq.gov/perspective/application-safety-ii-principles
August 28, 2024 - Each team is formally chartered by an executive leadership team accountable for operationalizing the … This work is then formally reported to and acted on by the accountable leadership team.