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psnet.ahrq.gov/issue/quality-and-safety-education-nurses-nursing-leadership-skills-exercise
July 29, 2020 - Commentary
Quality and safety education for nurses: a nursing leadership skills exercise.
Citation Text:
Harrison EM. Quality and safety education for nurses: a nursing leadership skills exercise. J Nurs Educ. 2014;53(6):356-361. doi:10.3928/01484834-20140512-01.
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psnet.ahrq.gov/issue/second-victim-phenomenon
July 10, 2024 - Review
Second-victim phenomenon.
Citation Text:
New L, Lambeth T. Second-victim phenomenon. Nurs Clin North Am. 2024;59(1):141-152. doi:10.1016/j.cnur.2023.11.011.
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psnet.ahrq.gov/issue/disclosing-harmful-pathology-errors-patients
May 18, 2022 - Commentary
Disclosing harmful pathology errors to patients.
Citation Text:
Dintzis SM, Gallagher TH. Disclosing harmful pathology errors to patients. Am J Clin Pathol. 2009;131(4):463-5. doi:10.1309/AJCPIO5SHDOD6URI.
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www.ahrq.gov/news/newsroom/case-studies/201524.html
August 01, 2015 - Aurora Health Care Embraces AHRQ’s CUSP Method to Protect Patient Safety
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August 2015
Fourteen hospitals operated by Aurora Health Care in eastern Wisconsin reduced central line-associated bloodstream infections (CLABSI) in intensive care units by 65 percent after adopting pat…
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www.ahrq.gov/news/newsroom/case-studies/cquips1301.html
November 01, 2012 - Newman Memorial Hospital Implements AHRQ's Patient Safety Culture Survey
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November 2012
Newman Memorial Hospital, a 79-bed acute hospital in Oklahoma, first implemented AHRQ's "Hospital Survey on Patient Safety Culture" in 2006, when concern about the hospital's patient safety …
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psnet.ahrq.gov/issue/handovers-or-icu
January 03, 2017 - Commentary
Handovers from the OR to the ICU.
Citation Text:
Bonifacio AS, Segall N, Barbeito A, et al. Handovers from the OR to the ICU. Int Anesthesiol Clin. 2013;51(1):43-61. doi:10.1097/AIA.0b013e31826f2b0e.
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psnet.ahrq.gov/issue/model-developing-high-reliability-teams
September 01, 2018 - Commentary
A model for developing high-reliability teams.
Citation Text:
Riley W, Davis SE, Miller KK, et al. A model for developing high-reliability teams. J Nurs Manag. 2010;18(5):556-63. doi:10.1111/j.1365-2834.2010.01121.x.
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psnet.ahrq.gov/issue/ihi-skilled-nursing-facility-trigger-tool-measuring-adverse-events
February 15, 2017 - Book/Report
IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events.
Citation Text:
IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events. Adler L, Moore J, Federico F. Cambridge, MA: Institute for Healthcare Improvement; November 2015.
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psnet.ahrq.gov/issue/economics-medication-safety-improving-medication-safety-through-collective-real-time-learning
October 07, 2020 - Book/Report
Economics of Medication Safety. Improving Medication Safety Through Collective, Real-time Learning.
Citation Text:
Economics of Medication Safety. Improving Medication Safety Through Collective, Real-time Learning. de Bienassis K, Esmail L, Lopert R, Klazinga N for the O…
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psnet.ahrq.gov/issue/disclosing-medical-errors-patients-challenge-health-care-professionals-and-institutions
April 19, 2017 - Commentary
Disclosing medical errors to patients: a challenge for health care professionals and institutions.
Citation Text:
Levinson W. Disclosing medical errors to patients: a challenge for health care professionals and institutions. Patient Educ Couns. 2009;76(3):296-9. doi:10.1016/…
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psnet.ahrq.gov/issue/health-literacy-and-mortality-among-elderly-persons
April 24, 2018 - Study
Health literacy and mortality among elderly persons.
Citation Text:
Baker DW, Wolf MS, Feinglass J, et al. Health literacy and mortality among elderly persons. Arch Intern Med. 2007;167(14):1503-9.
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psnet.ahrq.gov/issue/effect-comprehensive-obstetric-patient-safety-program-compensation-payments-and-sentinel
July 26, 2010 - Study
Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events.
Citation Text:
Grunebaum A, Chervenak F, Skupski D. Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. Am J Obstet Gyneco…
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psnet.ahrq.gov/issue/safety-analysis-over-time-seven-major-changes-adverse-event-investigation
September 24, 2018 - Commentary
Safety analysis over time: seven major changes to adverse event investigation.
Citation Text:
Vincent CA, Carthey J, Macrae C, et al. Safety analysis over time: seven major changes to adverse event investigation. Implementation Science. 2017;12(1). doi:10.1186/s13012-017-0695-…
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psnet.ahrq.gov/issue/evaluating-physician-performance-individualizing-care-pilot-study-tracking-contextual-errors
September 20, 2011 - Study
Evaluating physician performance at individualizing care: a pilot study tracking contextual errors in medical decision making.
Citation Text:
Weiner SJ, Schwartz A, Yudkowsky R, et al. Evaluating physician performance at individualizing care: a pilot study tracking contextual err…
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psnet.ahrq.gov/issue/understanding-liability-risk-using-health-care-artificial-intelligence-tools
April 03, 2024 - Commentary
Understanding liability risk from using health care artificial intelligence tools.
Citation Text:
Mello MM, Guha N. Understanding liability risk from using health care artificial intelligence tools. N Engl J Med. 2024;390(3):271-278. doi:10.1056/nejmhle2308901.
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psnet.ahrq.gov/issue/adverse-events-medicine-easy-count-complicated-understand-and-complex-prevent
July 15, 2009 - Commentary
Adverse events in medicine: easy to count, complicated to understand, and complex to prevent.
Citation Text:
Amalberti R, Benhamou D, Auroy Y, et al. Adverse events in medicine: easy to count, complicated to understand, and complex to prevent. J Biomed Inform. 2011;44(3):390…
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psnet.ahrq.gov/issue/towards-safer-better-healthcare-harnessing-natural-properties-complex-sociotechnical-systems
April 08, 2011 - Commentary
Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems.
Citation Text:
Braithwaite J, Runciman WB, Merry AF. Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems. Qual Saf Health …
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psnet.ahrq.gov/issue/review-australian-incident-monitoring-system
July 23, 2008 - Study
Review of the Australian Incident Monitoring System.
Citation Text:
Spigelman AD, Swan J. Review of the Australian incident monitoring system. ANZ J Surg. 2005;75(8):657-61.
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psnet.ahrq.gov/issue/hidden-plain-sight-reconsidering-use-race-correction-clinical-algorithms
September 23, 2020 - Commentary
Classic
Hidden in plain sight — reconsidering the use of race correction in clinical algorithms.
Citation Text:
Vyas DA, Eisenstein LG, Jones DS. Hidden in plain sight — reconsidering the use of race correction in clinical algorithms. N Engl J Med. 20…
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psnet.ahrq.gov/issue/committed-safety-ten-case-studies-reducing-harm-patients
July 31, 2012 - Book/Report
Committed to Safety: Ten Case Studies on Reducing Harm to Patients.
Citation Text:
Committed to Safety: Ten Case Studies on Reducing Harm to Patients. McCarthy D, Blumenthal D. New York, NY: Commonwealth Fund; 2006.
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