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psnet.ahrq.gov/node/867849/psn-pdf
February 26, 2025 - High Reliability Organization (HRO) Principles and Patient
Safety
February 26, 2025
Vogus T, Lee M, Mossburg SE. High Reliability Organization (HRO) Principles and Patient Safety. PSNet
[internet]. 2025.
https://psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
In To Err I…
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psnet.ahrq.gov/node/33695/psn-pdf
April 01, 2010 - #ref17
https://psnet.ahrq.gov//#ref20
https://psnet.ahrq.gov//#ref20
In the absence of a national approach
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.167_slideshow.ppt
January 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case January 2008
How Do Providers Recover from Errors?
Source and Credits
This presentation is based on the January 2008 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Colin P. West, MD, PhD, Mayo Clini…
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psnet.ahrq.gov/node/50391/psn-pdf
September 25, 2019 - Think Like a Surgeon
September 25, 2019
Cooper Z. Think Like a Surgeon. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/think-surgeon
The Case
A patient with a history of T6 paraplegia due to a motor vehicle accident was brought to the emergency
department due to delirium. He was found to be hypotensive and…
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psnet.ahrq.gov/node/33772/psn-pdf
September 01, 2014 - An alternative approach would be to say we must be even more proactive.
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psnet.ahrq.gov/node/46746/psn-pdf
March 07, 2018 - Safety with nebulized medications requires an
interdisciplinary team approach. … https://psnet.ahrq.gov/issue/safety-nebulized-medications-requires-interdisciplinary-team-approach
Myriad … https://psnet.ahrq.gov/issue/safety-nebulized-medications-requires-interdisciplinary-team-approach
https
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psnet.ahrq.gov/node/40206/psn-pdf
June 15, 2011 - The authors argue that their findings reinforce the need to adopt a systems
approach to prevention rather … swiss-cheese-model
https://psnet.ahrq.gov/issue/critical-incident-technique
https://psnet.ahrq.gov/primer/systems-approach … https://psnet.ahrq.gov/primer/systems-approach
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psnet.ahrq.gov/node/43218/psn-pdf
July 28, 2014 - The approach consists of students enhancing
their clinical skills, analyzing information to augment … decision making, and applying a systems approach to
detect underlying causes. … principles-risk-management-and-patient-safety
https://psnet.ahrq.gov/issue/yours-learning-organization
https://psnet.ahrq.gov/primer/systems-approach
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psnet.ahrq.gov/issue/interprofessional-approaches-patient-safety
October 15, 2008 - Special or Theme Issue
Interprofessional Approaches to Patient Safety.
Citation Text:
Interprofessional Approaches to Patient Safety. J Interprof Care. 2006;20(5):461-563.
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psnet.ahrq.gov/node/42363/psn-pdf
September 19, 2013 - characterisation of patient safety hazards
in community pharmacies using a sociotechnical systems
approach … characterisation of patient safety hazards in community pharmacies
using a sociotechnical systems approach … e-prescribing-characterisation-patient-safety-hazards-community-pharmacies-using
https://psnet.ahrq.gov/issue/e-prescribing-focused-review-and-new-approach-addressing-safety-pharmacies-and-primary-care
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psnet.ahrq.gov/node/46622/psn-pdf
December 06, 2017 - https://psnet.ahrq.gov/issue/white-paper-recommendation-systems-based-practice-competency
A systems approach … /white-paper-recommendation-systems-based-practice-competency
https://psnet.ahrq.gov/primer/systems-approach … psnet.ahrq.gov/primer/patient-safety-101
https://psnet.ahrq.gov/issue/quality-and-safety-nursing-competency-approach-improving-outcomes-second-edition
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psnet.ahrq.gov/node/46326/psn-pdf
October 18, 2017 - Surgical Patient Safety: A Case-Based Approach.
October 18, 2017
Stahel PF, ed. … https://psnet.ahrq.gov/issue/surgical-patient-safety-case-based-approach
Surgical residency can be a … https://psnet.ahrq.gov/issue/surgical-patient-safety-case-based-approach
https://psnet.ahrq.gov/issue
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psnet.ahrq.gov/node/41300/psn-pdf
April 22, 2012 - knowledge-self-efficacy
A 3-day course for second year medical students that emphasized teamwork skills and the systems
approach … day-patient-safety-curriculum-advance-knowledge-self-efficacy
https://psnet.ahrq.gov/primer/systems-approach … https://psnet.ahrq.gov/primer/systems-approach
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psnet.ahrq.gov/node/35501/psn-pdf
June 15, 2011 - Lucian Leape, begins with a retrospective view on the
birth of patient safety initiatives, the systems approach … to addressing problems, progress made in changing
systems, and challenges with this systems approach … ethical-issues-patient-safety
https://psnet.ahrq.gov/issue/interview-lucian-leape
https://psnet.ahrq.gov/primer/systems-approach
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psnet.ahrq.gov/node/44624/psn-pdf
March 02, 2016 - Researchers found that the most common patient safety research topic using this approach to date is … The authors suggest that more methodological rigor is needed to apply
the approach to patient safety … what-methods-are-used-apply-positive-deviance-within-healthcare-organisations-systematic
https://psnet.ahrq.gov/issue/positive-deviance-different-approach-achieving-patient-safety
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psnet.ahrq.gov/node/44689/psn-pdf
February 24, 2018 - concept of a just culture has become popular for balancing individual accountability with a systems
approach … https://psnet.ahrq.gov/perspective/accountability-patient-safety
https://psnet.ahrq.gov/primer/systems-approach … https://psnet.ahrq.gov/primer/systems-approach
https://psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
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psnet.ahrq.gov/node/44812/psn-pdf
February 15, 2017 - Investigators also tested a combined approach. … Although both team training and system redesign
individually demonstrated improvement, the combined approach … was more successful than either individual
approach.
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psnet.ahrq.gov/perspective/accountability-patient-safety
January 01, 2018 - New articles exploring the role of individual skill in safety have heightened the need for an approach … This approach to mistakes was an ineffective strategy for preventing further patient safety mishaps, … This approach was codified as the cornerstone for the field of patient safety by its central role in … The systems-based approach was not only more likely to fix underlying patient safety problems, but … A prior PSNet perspective summarizes a stepwise approach for managing problem behaviors.
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psnet.ahrq.gov/node/46781/psn-pdf
August 20, 2018 - risk industries may not be
straightforward: a qualitative study of the hierarchy of
risk controls approach … risk industries may not be straightforward: a
qualitative study of the hierarchy of risk controls approach … /errors-and-near-misses-what-health-care-could-learn-aviation
https://psnet.ahrq.gov/primer/systems-approach
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psnet.ahrq.gov/node/41858/psn-pdf
November 21, 2012 - This study
applied the systems approach to analyze cases presented at surgical M&M conferences over … disorganized-care-findings-iterative-depth-analysis-surgical-morbidity-and-mortality
https://psnet.ahrq.gov/primer/systems-approach … /discussion-medical-errors-morbidity-and-mortality-conferences
https://psnet.ahrq.gov/issue/systems-approach-morbidity-and-mortality-conference