-
psnet.ahrq.gov/node/46682/psn-pdf
January 24, 2018 - AHRQ Safety Program for Surgery.
January 24, 2018
Rockville, MD: Agency for Healthcare Research and Quality. December 2017. AHRQ Publication No.
16(18)-0004-1-EF.
https://psnet.ahrq.gov/issue/ahrq-safety-program-surgery
Large-scale collaboratives have achieved success in implementing patient safety improvements. T…
-
psnet.ahrq.gov/node/43390/psn-pdf
July 30, 2014 - Hazards tied to medical records rush.
July 30, 2014
Rowland C.
https://psnet.ahrq.gov/issue/hazards-tied-medical-records-rush
Government incentives have led to rapid development and adoption of electronic health records (EHRs).
This newspaper article examines some of the unintended consequences of implementing ele…
-
psnet.ahrq.gov/node/46380/psn-pdf
September 06, 2017 - What defines a high-performing health system: a
systematic review.
September 6, 2017
Ahluwalia SC, Damberg CL, Silverman M, et al. What Defines a High-Performing Health Care Delivery
System: A Systematic Review. Jt Comm J Qual Patient Saf. 2017;43(9):450-459.
doi:10.1016/j.jcjq.2017.03.010.
https://psnet.ahrq.gov…
-
psnet.ahrq.gov/node/44032/psn-pdf
April 01, 2015 - ACOG Committee Opinion #621: patient safety and health
information technology.
April 1, 2015
Improvement C on PS and Q, Management C on P. Committee opinion no. 621: Patient safety and health
information technology. Obstet Gynecol. 2015;125(1):282-3. doi:10.1097/01.AOG.0000459867.14114.7a.
https://psnet.ahrq.gov/i…
-
psnet.ahrq.gov/node/43456/psn-pdf
October 03, 2017 - Veterans' Access to Care through Choice, Accountability,
and Transparency Act of 2014.
October 3, 2017
HR 3230, 113th Congress: 2014.
https://psnet.ahrq.gov/issue/veterans-access-care-through-choice-accountability-and-transparency-act-
2014
The Veterans Affairs (VA) health system has both achieved success and str…
-
psnet.ahrq.gov/node/36511/psn-pdf
January 07, 2011 - Facing ambiguous threats.
January 7, 2011
Roberto MA, Bohmer RMJ, Edmondson A. Facing ambiguous threats. Harv Bus Rev. 2006;84(11):106-13,
157.
https://psnet.ahrq.gov/issue/facing-ambiguous-threats
This study describes how organizations respond to signs that may or may not portend future
catastrophes. The authors…
-
psnet.ahrq.gov/node/45178/psn-pdf
December 04, 2016 - Do physicians clean their hands? Insights from a covert
observational study.
December 4, 2016
Kovacs-Litman A, Wong K, Shojania KG, et al. Do physicians clean their hands? Insights from a covert
observational study. J Hosp Med. 2016;11(12):862-864. doi:10.1002/jhm.2632.
https://psnet.ahrq.gov/issue/do-physicians-c…
-
psnet.ahrq.gov/node/45232/psn-pdf
August 10, 2016 - Promoting patient safety with perioperative hand-off
communication.
August 10, 2016
Robinson NL. Promoting Patient Safety With Perioperative Hand-off Communication. J Perianesth Nurs.
2016;31(3):245-53. doi:10.1016/j.jopan.2014.08.144.
https://psnet.ahrq.gov/issue/promoting-patient-safety-perioperative-hand-commun…
-
psnet.ahrq.gov/node/46551/psn-pdf
October 25, 2017 - Inpatient notes: diagnostic excellence starts with an
incessant watch.
October 25, 2017
Dhaliwal G. Annals for Hospitalists Inpatient Notes - Diagnostic Excellence Starts With an Incessant Watch.
Ann Intern Med. 2017;167(8):HO2-HO3. doi:10.7326/m17-2447.
https://psnet.ahrq.gov/issue/inpatient-notes-diagnostic-exce…
-
psnet.ahrq.gov/node/34715/psn-pdf
February 18, 2011 - Continuous improvement as an ideal in health care.
February 18, 2011
Berwick D. Continuous improvement as an ideal in health care. New Engl J Med. 1989;320(1):53-56.
https://psnet.ahrq.gov/issue/continuous-improvement-ideal-health-care
Two approaches to improving quality in health care are illustrated in this artic…
-
psnet.ahrq.gov/node/43943/psn-pdf
December 04, 2015 - Culture Change in the NHS: Applying the Lessons of the
Francis Inquiries.
December 4, 2015
Department of Health. London, England: Crown Publishing; February 2015. ISBN: 9781474112116.
https://psnet.ahrq.gov/issue/culture-change-nhs-applying-lessons-francis-inquiries
The Francis inquiry uncovered numerous problems …
-
psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - SPOTLIGHT CASE
Getting to the Root of the Matter
Citation Text:
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Schola…
-
psnet.ahrq.gov/web-mm/room-without-orders
September 01, 2011 - SPOTLIGHT CASE
A Room Without Orders
Citation Text:
Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3…
-
psnet.ahrq.gov/web-mm/monitoring-fetal-health
September 08, 2010 - SPOTLIGHT CASE
Monitoring Fetal Health
Citation Text:
Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar BibTeX EndNot…
-
psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
March 30, 2020 - In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD
March 30, 2020
Also Read the Essay
Citation Text:
In Conversation With.. Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD. PSNet [internet]. 2020.In Conversation With... Ann Gaffey, RN, MS…
-
psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - The Impact of Communication on Medication Errors
March 15, 2021
Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors
The Case
A 93-year-old man with a history of chronic systolic heart failure…
-
psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
April 26, 2023 - In Conversation With… Mark Chassin, MD, MPP, MPH
April 1, 2017
Citation Text:
In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Cit…
-
psnet.ahrq.gov/node/49682/psn-pdf
April 01, 2013 - From Possible to Probable to Sure to Wrong—Premature
Closure and Anchoring in a Complicated Case
April 1, 2013
Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a
Complicated Case. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premat…
-
psnet.ahrq.gov/node/72516/psn-pdf
November 25, 2020 - Premature Closure: Was It Just Syncope?
November 25, 2020
Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…
-
psnet.ahrq.gov/node/60267/psn-pdf
March 01, 2021 - Affordable Housing Community Offers Seniors Onsite
Health Care Coordination and Support, Reducing Hospital
Admissions and Falls and Improving Resident Health
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-h…