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psnet.ahrq.gov/issue/forgive-and-remember-managing-medical-failure-2nd-ed
March 27, 2005 - Book/Report
Classic
Forgive and Remember: Managing Medical Failure. 2nd ed.
Citation Text:
Forgive and Remember: Managing Medical Failure. 2nd ed. Bosk CL.Chicago, IL: University of Chicago Press; 2003. ISBN: 9780226066783.
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psnet.ahrq.gov/node/72561/psn-pdf
December 09, 2020 - Artificial Intelligence in Health Care: Benefits and
Challenges of Technologies to Augment Patient Care.
December 9, 2020
Washington DC; United States Government Accountability Office; November 26, 2020. Publication GAO-
21-7SP.
https://psnet.ahrq.gov/issue/artificial-intelligence-health-care-benefits-and-challeng…
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psnet.ahrq.gov/node/837032/psn-pdf
May 04, 2022 - The patient's "story": an examination of patient-reported
safety incidents in general practice.
May 4, 2022
Madden C, Lydon S, Murphy AW, et al. The patient’s “story”: an examination of patient-reported safety
incidents in general practice. Fam Pract. 2022;39(6):1095-1102. doi:10.1093/fampra/cmac033.
https://psnet…
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psnet.ahrq.gov/node/837974/psn-pdf
August 31, 2022 - Fostering a just culture in healthcare organizations:
experiences in practice.
August 31, 2022
van Baarle E, Hartman L, Rooijakkers S, et al. Fostering a just culture in healthcare organizations:
experiences in practice. BMC Health Serv Res. 2022;22(1):1035. doi:10.1186/s12913-022-08418-z.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/850929/psn-pdf
June 21, 2023 - Requirements for implementing a 'just culture' within
healthcare organisations: an integrative review.
June 21, 2023
Murray JS, Lee J, Larson S, et al. Requirements for implementing a ‘just culture’ within healthcare
organisations: an integrative review. BMJ Open Qual. 2023;12(2):e002237. doi:10.1136/bmjoq-2022-
0…
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psnet.ahrq.gov/issue/learning-candour-and-accountability-review-way-nhs-trusts-review-and-investigate-deaths
January 23, 2019 - Book/Report
Learning, Candour and Accountability. A Review of the Way NHS Trusts Review and Investigate the Deaths of Patients in England.
Citation Text:
Learning, Candour and Accountability. A Review of the Way NHS Trusts Review and Investigate the Deaths of Patients in England. Newcast…
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psnet.ahrq.gov/issue/paying-piper-investing-infrastructure-patient-safety
July 01, 2017 - Commentary
Classic
Paying the piper: investing in infrastructure for patient safety.
Citation Text:
Pronovost P, Rosenstein BJ, Paine LA, et al. Paying the piper: investing in infrastructure for patient safety. Jt Comm J Qual Patient Saf. 2008;34(6):342-8.
Co…
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psnet.ahrq.gov/node/42809/psn-pdf
January 01, 2015 - Patient Safety Measures.
December 11, 2013
Washington, DC: National Quality Forum.
https://psnet.ahrq.gov/issue/patient-safety-measures
This Web site tracks the progress of the development and review of measures to enhance reporting and
accountability of health care organizations in addressing risks to patient sa…
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psnet.ahrq.gov/issue/approaches-and-challenges-electronically-matching-patients-records-across-providers
September 25, 2019 - Book/Report
Approaches and Challenges to Electronically Matching Patients' Records Across Providers.
Citation Text:
Approaches and Challenges to Electronically Matching Patients' Records Across Providers. Washington, DC: United States Government Accountability Office; January 2019. Publi…
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psnet.ahrq.gov/issue/trends-pregnancy-related-deaths-and-federal-efforts-reduce-them
May 27, 2020 - Book/Report
Trends in Pregnancy-Related Deaths and Federal Efforts to Reduce Them.
Citation Text:
Trends in Pregnancy-Related Deaths and Federal Efforts to Reduce Them. Washington, DC: United States Government Accountability Office; March 2020. Publication GAO-20-248.
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psnet.ahrq.gov/issue/defense-health-agency-processes-responding-provider-quality-and-safety-concerns
December 09, 2020 - Book/Report
Defense Health Agency Processes for Responding to Provider Quality and Safety Concerns.
Citation Text:
Defense Health Agency Processes for Responding to Provider Quality and Safety Concerns. Washington DC; Governmental Accountability Office; December 1, 2020. Publication GAO-…
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psnet.ahrq.gov/issue/patient-options-safe-and-effective-disposal-unused-opioids
March 06, 2019 - Book/Report
Patient Options for Safe and Effective Disposal of Unused Opioids.
Citation Text:
Patient Options for Safe and Effective Disposal of Unused Opioids. Washington, DC: United States Government Accountability Office; September 2019. Publication GAO-19-650.
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psnet.ahrq.gov/issue/dod-and-va-health-care-medication-needs-during-transitions-may-not-be-managed-all
December 09, 2020 - Book/Report
DOD and VA Health Care: Medication Needs During Transitions May Not Be Managed for All Servicemembers.
Citation Text:
DOD and VA Health Care: Medication Needs During Transitions May Not Be Managed for All Servicemembers. Washington, DC: United States Government Accoun…
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psnet.ahrq.gov/issue/community-living-centers-va-needs-strengthen-its-approach-addressing-resident-complaints
October 12, 2022 - Book/Report
Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints.
Citation Text:
Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints. Washington, DC: United States Government Accountability Office; N…
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psnet.ahrq.gov/node/50385/psn-pdf
January 01, 2020 - How hospitals select their patient safety priorities: an
exploratory study of four Veterans Health Administration
hospitals.
September 25, 2019
George J, Parker VA, Sullivan JL, et al. How hospitals select their patient safety priorities. Health Care
Manag Rev. 2020;45(4):E56-E67. doi:10.1097/hmr.0000000000000260.…
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psnet.ahrq.gov/node/855087/psn-pdf
November 08, 2023 - Middle manager responses to hospital co-workers'
unprofessional behaviours within the context of a
professional accountability culture change program: a
qualitative analysis.
November 8, 2023
Bagot KL, McInnes E, Mannion R, et al. Middle manager responses to hospital co-workers’ unprofessional
behaviours within t…
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psnet.ahrq.gov/issue/pursuing-professional-accountability-evidence-based-approach-addressing-residents-behavioral
January 18, 2012 - Commentary
Pursuing professional accountability: an evidence-based approach to addressing residents with behavioral problems.
Citation Text:
Sanfey H, DaRosa DA, Hickson GB, et al. Pursuing professional accountability: an evidence-based approach to addressing residents with behavioral pr…
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psnet.ahrq.gov/node/47823/psn-pdf
March 13, 2019 - Greater Focus on Credentialing Needed to Prevent
Disqualified Providers From Delivering Patient Care.
March 13, 2019
Washington, DC: United States Government Accountability Office; February 2019. Publication GAO-19-6.
https://psnet.ahrq.gov/issue/greater-focus-credentialing-needed-prevent-disqualified-providers-del…
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psnet.ahrq.gov/node/39381/psn-pdf
March 17, 2010 - Getting it right when things go wrong.
March 17, 2010
Pettker CM, Funai EF. Getting it right when things go wrong. JAMA. 2010;303(10):977-8.
doi:10.1001/jama.2010.256.
https://psnet.ahrq.gov/issue/getting-it-right-when-things-go-wrong
This brief commentary discusses the relationship between blame, accountability, …
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psnet.ahrq.gov/issue/health-care-risk-managers-consensus-management-inappropriate-behaviors-among-hospital-staff
June 16, 2021 - Study
Health care risk managers' consensus on the management of inappropriate behaviors among hospital staff.
Citation Text:
Zadeh SE, Haussmann R, Barton CD. Health care risk managers' consensus on the management of inappropriate behaviors among hospital staff. J Healthc Risk Manag. 201…