-
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…
-
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…
-
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…
-
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…
-
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…
-
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…
-
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.
Copy Citat…
-
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…
-
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…
-
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-…
-
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…
-
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.…
-
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, …
-
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.
-
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.
-
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…
-
psnet.ahrq.gov/issue/patient-safety-and-problem-many-hands
June 16, 2021 - Commentary
Patient safety and the problem of many hands.
Citation Text:
Dixon-Woods M, Pronovost P. Patient safety and the problem of many hands. BMJ Qual Saf. 2016;25(7):485-488. doi:10.1136/bmjqs-2016-005232.
Copy Citation
Format:
DOI Google Scholar PubMed BibTeX EndNote …
-
psnet.ahrq.gov/node/35594/psn-pdf
January 04, 2006 - VA Patient Safety Program: A Cultural Perspective at Four
Medical Facilities.
January 4, 2006
General Accounting Office. Washington, DC: Government Printing Office; 2004. Report no. GAO-05-83.
https://psnet.ahrq.gov/issue/va-patient-safety-program-cultural-perspective-four-medical-facilities
The Government Account…
-
psnet.ahrq.gov/node/838132/psn-pdf
September 21, 2022 - Pathology trainees rarely report safety incidents: a review
of 13,722 safety reports and a call to action.
September 21, 2022
Harris CK, Chen Y, Yarsky B, et al. Pathology trainees rarely report safety incidents: a review of 13,722
safety reports and a call to action. Acad Pathol. 2022;9(1):100049. doi:10.1016/j.ac…
-
psnet.ahrq.gov/node/60518/psn-pdf
May 27, 2020 - Infection Control Deficiencies Were Widespread and
Persistent in Nursing Homes Prior to COVID-19 Pandemic.
May 27, 2020
Washington, DC: United States Government Accountability Office; May 20, 2020. Publication GAO-20-
576R.
https://psnet.ahrq.gov/issue/infection-control-deficiencies-were-widespre…