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psnet.ahrq.gov/issue/apsf-endorsed-statement-revising-recommendations-patient-monitoring-during-anesthesia
July 25, 2018 - Organizational Policy/Guidelines
APSF endorsed statement on revising recommendations for patient monitoring during anesthesia.
Citation Text:
APSF endorsed statement on revising recommendations for patient monitoring during anesthesia. The APSF Committee on Technology. APSF Newsletter.&n…
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psnet.ahrq.gov/issue/seven-leadership-leverage-points-organization-level-improvement-health-care
November 18, 2011 - Book/Report
Seven Leadership Leverage Points for Organization-Level Improvement in Health Care. Second edition.
Citation Text:
Seven Leadership Leverage Points for Organization-Level Improvement in Health Care. Second edition. Reinertsen JL, Bisognano M, Pugh MD. Cambridge, MA: Institute…
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psnet.ahrq.gov/issue/enacting-washington-state-patient-safety-act-requiring-hospital-staffing-plans-nursing
May 04, 2015 - Legislation/Case Law
Enacting the Washington state patient safety act requiring hospital staffing plans for nursing services and establishing recordkeeping and reporting requirements.
Citation Text:
Enacting the Washington state patient safety act requiring hospital staffing plans for n…
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psnet.ahrq.gov/issue/safety-culture-building-and-sustaining-cultural-change-aviation-and-healthcare
August 02, 2016 - Book/Report
Safety Culture: Building and Sustaining a Cultural Change in Aviation and Healthcare.
Citation Text:
Safety Culture: Building and Sustaining a Cultural Change in Aviation and Healthcare. Patankar MS, Brown JP, Sabin EJ, Bigda-Peyton TG. Burlington, VT: Ashgate; 2012. ISBN: 97…
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psnet.ahrq.gov/issue/2019-john-m-eisenberg-patient-safety-and-quality-award-recipients
May 30, 2012 - Award Recipient
2019 John M. Eisenberg Patient Safety and Quality Award Recipients.
Citation Text:
2019 John M. Eisenberg Patient Safety and Quality Award Recipients. Oakbrook Terrace, IL; Joint Commission: May 13 2020.
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psnet.ahrq.gov/issue/2018-john-m-eisenberg-patient-safety-and-quality-award-recipients-announced
February 28, 2018 - Press Release/Announcement
2018 John M. Eisenberg Patient Safety and Quality Award Recipients Announced.
Citation Text:
2018 John M. Eisenberg Patient Safety and Quality Award Recipients Announced. Joint Commission.
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psnet.ahrq.gov/issue/2007-john-m-eisenberg-patient-safety-and-quality-award-recipients
February 28, 2018 - Press Release/Announcement
2007 John M. Eisenberg Patient Safety and Quality Award Recipients.
Citation Text:
2007 John M. Eisenberg Patient Safety and Quality Award Recipients. Joint Commission.
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psnet.ahrq.gov/issue/oxford-professional-practice-handbook-patient-safety
June 16, 2012 - Book/Report
Oxford Professional Practice: Handbook of Patient Safety.
Citation Text:
Oxford Professional Practice: Handbook of Patient Safety. Lachman P, Runnacles J, Jayadev A et al, eds. London, England; Oxford University Press; 2022. ISBN: 9780192846877.
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psnet.ahrq.gov/web-mm/hazards-loading-doses
December 01, 2003 - Hazards of Loading Doses
Citation Text:
Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/issue/patient-safety-disclosure-medical-errors-and-risk-mitigation
June 07, 2017 - Commentary
Patient safety: disclosure of medical errors and risk mitigation.
Citation Text:
Moffatt-Bruce SD, Ferdinand FD, Fann J. Patient Safety: Disclosure of Medical Errors and Risk Mitigation. Ann Thorac Surg. 2016;102(2):358-62. doi:10.1016/j.athoracsur.2016.06.033.
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psnet.ahrq.gov/issue/passing-yo-mama-test
February 15, 2023 - Commentary
Passing the "Yo' Mama" test.
Citation Text:
Blair R. Passing the "Yo' Mama" test. Atlanta healthcare organization follows the beat of a different drummer in achieving 100 percent CPOE adoption. Health Manag Technol. 2006;27(6):14, 16, 18.
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psnet.ahrq.gov/issue/effects-multifaceted-medication-reconciliation-quality-improvement-intervention-patient
April 12, 2023 - Study
Emerging Classic
Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study.
Citation Text:
Schnipper JL, Mixon A, Stein J, et al. Effects of a multifaceted medication reconcil…
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psnet.ahrq.gov/node/33804/psn-pdf
March 03, 2016 - In Conversation With… Paul McGann, MD
March 1, 2016
In Conversation With… Paul McGann, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
Editor's note: Dr. McGann is the Chief Medical Officer for Quality Improvement at the Centers for
Medicare & Medicaid Services (CMS). He…
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psnet.ahrq.gov/node/38237/psn-pdf
October 05, 2021 - The Safety Competencies Framework.
October 5, 2021
Ottawa, ON: Canadian Patient Safety Institute; 2020.
https://psnet.ahrq.gov/issue/safety-competencies-framework
This initative defines competency domains for safe health care and outlines educational practices to
achieve them. The 2nd edition of the Patient Safety…
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psnet.ahrq.gov/issue/keeping-patients-safe-healthcare-organizations-structuration-theory-safety-culture
September 04, 2010 - Review
Keeping patients safe in healthcare organizations: a structuration theory of safety culture.
Citation Text:
Groves PS, Meisenbach RJ, Scott-Cawiezell J. Keeping patients safe in healthcare organizations: a structuration theory of safety culture. J Adv Nurs. 2011;67(8):1846-55. d…
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psnet.ahrq.gov/issue/nursing-home-error-and-level-staff-credentials
September 24, 2010 - Study
Nursing home error and level of staff credentials.
Citation Text:
Scott-Cawiezell J, Pepper GA, Madsen RW, et al. Nursing home error and level of staff credentials. Clin Nurs Res. 2007;16(1):72-8.
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psnet.ahrq.gov/issue/cognitive-systems-engineering-health-care
October 11, 2016 - Book/Report
Cognitive Systems Engineering in Health Care.
Citation Text:
Cognitive Systems Engineering in Health Care. Bisantz AM, Burns CM, Fairbanks RJ, eds. Boca Raton, FL: CRC Press; 2014. ISBN: 9781466587960.
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psnet.ahrq.gov/issue/engineering-learning-healthcare-system-look-future-workshop-summary
June 15, 2011 - Book/Report
Engineering a Learning Healthcare System: A Look at the Future: Workshop Summary.
Citation Text:
Engineering a Learning Healthcare System: A Look at the Future: Workshop Summary. Grossmann C, Goolsby WA, Olsen L, McGinnis JM; Institute of Medicine and National Academy of …
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psnet.ahrq.gov/issue/just-culture-after-mid-staffordshire
February 11, 2009 - Commentary
A just culture after Mid Staffordshire.
Citation Text:
Dekker SWA, Hugh TB. A just culture after Mid Staffordshire. BMJ Qual Saf. 2014;23(5):356-8. doi:10.1136/bmjqs-2013-002483.
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psnet.ahrq.gov/issue/fifth-discipline-art-practice-learning-organization-revised-updated-edition
May 12, 2010 - Book/Report
Classic
The Fifth Discipline: The Art & Practice of The Learning Organization. Revised & Updated Edition.
Citation Text:
The Fifth Discipline: The Art & Practice of The Learning Organization. Revised & Updated Edition. Senge PM. New York, NY: Currenc…