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psnet.ahrq.gov/node/37536/psn-pdf
February 01, 2011 - Improving patient safety by taking systems seriously.
February 1, 2011
Shortell SM, Singer SJ. Improving patient safety by taking systems seriously. JAMA. 2008;299(4):445-447.
doi:10.1001/jama.299.4.445.
https://psnet.ahrq.gov/issue/improving-patient-safety-taking-systems-seriously
The authors advocate that system…
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psnet.ahrq.gov/node/854996/psn-pdf
April 09, 2003 - Safety paradoxes and safety culture.
April 9, 2003
Reason J. Safety paradoxes and safety culture. Inj Control Safety Promot. 2003;7(1):3-14.
doi:10.1076/1566-0974(200003)7:1;1-v;ft003.
https://psnet.ahrq.gov/issue/safety-paradoxes-and-safety-culture
Achieving a culture of safety is paramount in any high-risk indus…
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psnet.ahrq.gov/node/36340/psn-pdf
January 10, 2017 - American Hospital Association-McKesson Quest for
Quality Prize.
January 10, 2017
Jt Comm J Qual Patient Saf. 2006;32(10):541-572.
https://psnet.ahrq.gov/issue/american-hospital-association-mckesson-quest-quality-prize
These four articles highlight the achievements of the 2006 AHA McKesson Quest for Quality Prize w…
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psnet.ahrq.gov/node/36065/psn-pdf
May 27, 2011 - Passing the "Yo' Mama" test.
May 27, 2011
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.
https://psnet.ahrq.gov/issue/passing-yo-mama-test
This article discusses how a…
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psnet.ahrq.gov/node/38908/psn-pdf
January 03, 2017 - Rapid response systems in adult academic medical
centers.
January 3, 2017
Wood KA, Ranji SR, Ide B, et al. Rapid response systems in adult academic medical centers. Jt Comm J
Qual Patient Saf. 2009;35(9):475-82, 437.
https://psnet.ahrq.gov/issue/rapid-response-systems-adult-academic-medical-centers
This survey ch…
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psnet.ahrq.gov/node/45064/psn-pdf
April 20, 2016 - Making Care Safer.
April 20, 2016
Agency for Healthcare Research and Quality. Priorities in Focus. March 2016.
https://psnet.ahrq.gov/issue/making-care-safer
The National Quality Strategy is part of AHRQ's ongoing efforts to enhance patient safety. This brief
summarizes the results of the Partnership for Patients …
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psnet.ahrq.gov/node/38539/psn-pdf
January 02, 2017 - Rescue me: saving the vulnerable non-ICU patient
population.
January 2, 2017
Bader MK, Neal B, Johnson L, et al. Rescue me: saving the vulnerable non-ICU patient population. Jt
Comm J Qual Patient Saf. 2009;35(4):199-205.
https://psnet.ahrq.gov/issue/rescue-me-saving-vulnerable-non-icu-patient-population
A nurse-…
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psnet.ahrq.gov/node/36311/psn-pdf
October 04, 2006 - Eighth Annual National Patient Safety Foundation
Congress: Conference Proceedings.
October 4, 2006
Stepnick L, Edgman-Levitan S, Kaplan GS et al. J Patient Saf. 2006;2(2):58-69.
https://psnet.ahrq.gov/issue/eighth-annual-national-patient-safety-foundation-congress-conference-
proceedings
The authors summarize the…
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psnet.ahrq.gov/node/43145/psn-pdf
June 15, 2014 - The 2013 John M. Eisenberg Patient Safety and Quality
Awards.
June 15, 2014
Jt Comm J Qual Patient Saf. 2014;40(5):195-218.
https://psnet.ahrq.gov/issue/2013-john-m-eisenberg-patient-safety-and-quality-awards
Articles in this special issue highlight the achievements of the 2013 John M. Eisenberg Patient Safety and…
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psnet.ahrq.gov/node/41476/psn-pdf
June 20, 2012 - Interdisciplinary team training: five lessons learned.
June 20, 2012
Contratti F, Ng G, Deeb J. Interdisciplinary team training: five lessons learned. Am J Nurs. 2012;112(6):47-
52. doi:10.1097/01.NAJ.0000415127.84605.1f.
https://psnet.ahrq.gov/issue/interdisciplinary-team-training-five-lessons-learned
This commen…
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psnet.ahrq.gov/node/43295/psn-pdf
June 27, 2018 - Sound the alarm.
June 27, 2018
Addis LM, Cadet VN, Graham KC. Patient Saf Qual Healthc. May/June 2014.
https://psnet.ahrq.gov/issue/sound-alarm
Clinical alarms may contribute to errors due to alarm fatigue. This article describes four key elements to
achieve lasting improvement of alarm safety across organizations…
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psnet.ahrq.gov/node/34617/psn-pdf
March 07, 2005 - World Alliance for Patient Safety: forward programme.
March 7, 2005
Geneva, Switzerland: World Health Organization; 2004.
https://psnet.ahrq.gov/issue/world-alliance-patient-safety-forward-programme
This report outlines the six goals set by the new world alliance to achieve what no single country could
accomplish …
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psnet.ahrq.gov/node/45414/psn-pdf
August 17, 2016 - The next wave of hospital innovation to make patients
safer.
August 17, 2016
Ghaferi AA; Myers C; Sutcliffe KM; Pronovost PJ.
https://psnet.ahrq.gov/issue/next-wave-hospital-innovation-make-patients-safer
Achieving high reliability is a recognized goal for health care organizations. Reviewing current technical and…
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psnet.ahrq.gov/node/42874/psn-pdf
January 29, 2014 - Interdisciplinary Perspectives on Medical Error.
January 29, 2014
J Public Health Res. 2013;2:e22-e33.
https://psnet.ahrq.gov/issue/interdisciplinary-perspectives-medical-error
This special issue explores the challenges of advancing patient safety and highlights the value of
interdisciplinary collaboration to achi…
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psnet.ahrq.gov/node/39506/psn-pdf
March 23, 2011 - Readiness for organisational change among general
practice staff.
March 23, 2011
Christl B, Harris MF, Jayasinghe UW, et al. Readiness for organisational change among general practice
staff. Qual Saf Health Care. 2010;19(5):e12. doi:10.1136/qshc.2009.033373.
https://psnet.ahrq.gov/issue/readiness-organisational-ch…
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psnet.ahrq.gov/node/34733/psn-pdf
November 19, 2015 - Out of the Crisis.
November 19, 2015
Deming WE. Cambridge, MA: Massachusetts Institute of Technology, Center for Advanced Engineering
Study, 1986. ISBN: 9780911379013.
https://psnet.ahrq.gov/issue/out-crisis
Deming believes that American companies need to transform their method of management to engage and
compete…
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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - In Conversation with...James L. Reinertsen, MD
August 1, 2007
In Conversation with..James L. Reinertsen, MD. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
Editor's Note: James L. Reinertsen, MD, heads the Reinertsen Group, a prominent health care consulting
firm …
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psnet.ahrq.gov/web-mm/not-so-therapeutic-tap
December 01, 2014 - SPOTLIGHT CASE
Not-So-Therapeutic Tap
Citation Text:
Barsuk JH. Not-So-Therapeutic Tap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote …
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psnet.ahrq.gov/node/49657/psn-pdf
July 01, 2012 - Not-So-Therapeutic Tap
July 1, 2012
Barsuk JH. Not-So-Therapeutic Tap. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/not-so-therapeutic-tap
Case Objectives
Describe current issues with training clinicians to perform procedures.
Understand how simulation can be used to ensure trainees are competent in proc…
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psnet.ahrq.gov/node/46306/psn-pdf
August 02, 2017 - Use of cascading A3s to drive systemwide improvement.
August 2, 2017
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.
https://psnet.ahrq.gov/issue/use-cascading-a3s-drive-systemwide-impr…