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psnet.ahrq.gov/issue/improved-policies-and-oversight-needed-reviewing-and-reporting-providers-quality-and-safety
November 22, 2017 - Book/Report
Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns.
Citation Text:
Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns. Washington, DC: United States Government …
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psnet.ahrq.gov/issue/development-national-reporting-and-learning-system-england-and-wales-2001-2005
September 14, 2022 - Commentary
The development of the National Reporting and Learning System in England and Wales, 2001-2005.
Citation Text:
Williams SK, Osborn SS. The development of the National Reporting and Learning System in England and Wales, 2001–2005. Med J Aust. 2019;184(S10) (S10):s65-s68. doi:1…
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psnet.ahrq.gov/issue/mirror-mirror-wall-update-quality-american-health-care-through-patients-lens
August 15, 2007 - Book/Report
Mirror, Mirror on the Wall: An Update on the Quality of American Health Care Through the Patient's Lens.
Citation Text:
Mirror, Mirror on the Wall: An Update on the Quality of American Health Care Through the Patient's Lens. Davis K, Schoen S, Schoenbaum SC, et al. New Yo…
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psnet.ahrq.gov/issue/unmet-needs-teaching-physicians-provide-safe-patient-care
November 07, 2012 - Book/Report
Classic
Unmet Needs: Teaching Physicians to Provide Safe Patient Care.
Citation Text:
Unmet Needs: Teaching Physicians to Provide Safe Patient Care. Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; March 2010.
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psnet.ahrq.gov/issue/how-communication-failed-or-saved-day-counterfactual-accounts-medical-errors
September 21, 2022 - Study
How communication "failed" or "saved the day": counterfactual accounts of medical errors.
Citation Text:
Street RL, Petrocelli JV, Amroze A, et al. How Communication “Failed” or “Saved the Day”: Counterfactual Accounts of Medical Errors. J Patient Exp. 2020;7(6):1247-1254. doi:10.1…
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psnet.ahrq.gov/issue/incidence-and-nature-prescribing-and-medication-administration-errors-paediatric-inpatients
July 08, 2008 - Study
The incidence and nature of prescribing and medication administration errors in paediatric inpatients.
Citation Text:
Ghaleb M, Barber N, Franklin BD, et al. The incidence and nature of prescribing and medication administration errors in paediatric inpatients. Arch Dis Child. 201…
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psnet.ahrq.gov/issue/patterns-and-predictors-medication-discrepancies-primary-care
October 19, 2022 - Study
Patterns and predictors of medication discrepancies in primary care.
Citation Text:
Coletti DJ, Stephanou H, Mazzola N, et al. Patterns and predictors of medication discrepancies in primary care. J Eval Clin Pract. 2015;21(5):831-9. doi:10.1111/jep.12387.
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psnet.ahrq.gov/issue/systematic-review-effects-resident-work-hours-patient-safety
February 03, 2011 - Review
Systematic review: effects of resident work hours on patient safety.
Citation Text:
Fletcher KE, Davis SQ, Underwood W, et al. Systematic review: effects of resident work hours on patient safety. Ann Intern Med. 2004;141(11):851-857.
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psnet.ahrq.gov/issue/clinical-learning-environment-review-cler-program
November 18, 2020 - Multi-use Website
Clinical Learning Environment Review (CLER) Program.
Citation Text:
Clinical Learning Environment Review (CLER) Program. Accreditation Council for Graduate Medical Education.
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psnet.ahrq.gov/issue/telediagnosis-acute-care-implications-quality-and-safety-diagnosis
January 11, 2017 - Book/Report
Telediagnosis for Acute Care: Implications for the Quality and Safety of Diagnosis.
Citation Text:
Telediagnosis for Acute Care: Implications for the Quality and Safety of Diagnosis. Smith KM, Hunte HE, Graber ML. Rockville MD: Agency for Healthcare Research and Quality; Augu…
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psnet.ahrq.gov/issue/wrong-site-craniotomy-analysis-35-cases-and-systems-prevention
November 16, 2022 - Study
Wrong-site craniotomy: analysis of 35 cases and systems for prevention.
Citation Text:
Cohen FL, Mendelsohn D, Bernstein M. Wrong-site craniotomy: analysis of 35 cases and systems for prevention. J Neurosurg. 2010;113(3):461-73. doi:10.3171/2009.10.JNS091282.
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psnet.ahrq.gov/issue/handoff-communication-between-hospital-and-outpatient-dialysis-units-patient-discharge
August 20, 2018 - Study
Handoff communication between hospital and outpatient dialysis units at patient discharge: a qualitative study.
Citation Text:
Reilly JB, Marcotte LM, Berns JS, et al. Handoff communication between hospital and outpatient dialysis units at patient discharge: a qualitative study. …
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psnet.ahrq.gov/issue/addressing-medicines-bias-against-patients-who-are-overweight
May 15, 2019 - Commentary
Addressing medicine's bias against patients who are overweight.
Citation Text:
Rubin R. Addressing Medicine's Bias Against Patients Who Are Overweight. JAMA. 2019;321(10):925-927. doi:10.1001/jama.2019.0048.
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psnet.ahrq.gov/issue/inpatients-notes-sensemaking-fostering-shared-understanding-clinical-teams
November 25, 2020 - Commentary
Inpatients notes: sensemaking—fostering a shared understanding in clinical teams.
Citation Text:
Leykum LK, O'Leary KJ. Web Exclusives. Annals for Hospitalists Inpatient Notes - Sensemaking-Fostering a Shared Understanding in Clinical Teams. Ann Intern Med. 2017;167(4):HO2-HO3…
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psnet.ahrq.gov/issue/health-information-technology-vehicle-not-destination-conversation-david-j-brailer
March 19, 2019 - Commentary
Health information technology is a vehicle, not a destination: a conversation with David J. Brailer.
Citation Text:
Brailer DJ. Health information technology is a vehicle, not a destination: a conversation with David J. Brailer. Interview by Arnold Milstein. Health Aff (Mill…
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psnet.ahrq.gov/issue/vha-new-england-medication-error-prevention-initiative-model-long-term-improvement
January 04, 2017 - Commentary
The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives.
Citation Text:
Lesar TS, Anderson ER, Fields J, et al. The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives…
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psnet.ahrq.gov/issue/applying-trigger-tools-detect-adverse-events-associated-outpatient-surgery
November 10, 2015 - Study
Applying trigger tools to detect adverse events associated with outpatient surgery.
Citation Text:
Rosen AK, Mull HJ, Kaafarani HMA, et al. Applying trigger tools to detect adverse events associated with outpatient surgery. J Patient Saf. 2011;7(1):45-59. doi:10.1097/PTS.0b013e3182…
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psnet.ahrq.gov/issue/implementation-medication-reconciliation-process-ambulatory-internal-medicine-clinic
October 28, 2009 - Study
Implementation of a medication reconciliation process in an ambulatory internal medicine clinic.
Citation Text:
Nassaralla CL, Naessens JM, Chaudhry R, et al. Implementation of a medication reconciliation process in an ambulatory internal medicine clinic. Qual Saf Health Care. 20…
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psnet.ahrq.gov/node/43658/psn-pdf
December 19, 2014 - https://psnet.ahrq.gov/primer/handoffs-and-signouts
https://psnet.ahrq.gov/issue/interprofessional-approaches-patient-safety
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psnet.ahrq.gov/node/44702/psn-pdf
December 16, 2015 - that contribute to alarm
fatigue, this review outlines technical, organizational, and educational approaches