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psnet.ahrq.gov/issue/swapping-horses-midstream-factors-related-physicians-changing-their-minds-about-diagnosis
January 29, 2020 - Study
Swapping horses midstream: factors related to physicians' changing their minds about a diagnosis.
Citation Text:
Eva KW, Link CL, Lutfey KE, et al. Swapping horses midstream: factors related to physicians' changing their minds about a diagnosis. Acad Med. 2010;85(7):1112-7. doi:10.…
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psnet.ahrq.gov/issue/disclosure-coaching-ask-tell-ask-model-support-clinicians-disclosure-conversations
December 18, 2014 - Commentary
Disclosure coaching: an ask-tell-ask model to support clinicians in disclosure conversations.
Citation Text:
Shapiro J, Robins L, Galowitz P, et al. Disclosure Coaching: An Ask-Tell-Ask Model to Support Clinicians in Disclosure Conversations. J Patient Saf. 2021;17(8):e1364-e1…
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psnet.ahrq.gov/issue/improving-discharge-safety-pediatric-emergency-department
June 22, 2022 - Study
Improving discharge safety in a pediatric emergency department.
Citation Text:
Paydar-Darian N, Stack AM, Volpe D, et al. Improving discharge safety in a pediatric emergency department. Pediatrics. 2022;150(5):e2021054307. doi:10.1542/peds.2021-054307.
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psnet.ahrq.gov/issue/addressing-delays-medication-administration-patients-transferred-hospital-nursing-home-pilot
November 16, 2022 - Study
Addressing delays in medication administration for patients transferred from the hospital to the nursing home: a pilot quality improvement project.
Citation Text:
Ward KT, Bates-Jensen B, Eslami MS, et al. Addressing delays in medication administration for patients transferred …
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psnet.ahrq.gov/issue/development-and-expression-high-reliability-organization
November 03, 2021 - Commentary
Development and expression of a high-reliability organization.
Citation Text:
Phillips RA, Schwartz RL, Sostman HD, et al. Development and expression of a high-reliability organization. NEJM Catal Innov Care Deliv. 2021;2(12). doi:10.1056/cat.21.0314.
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psnet.ahrq.gov/issue/strategies-improve-patient-safety-outcome-indicator-preventing-or-reducing-falls
March 24, 2021 - Commentary
Strategies to improve the patient safety outcome indicator: preventing or reducing falls.
Citation Text:
Bright L. Strategies to improve the patient safety outcome indicator: preventing or reducing falls. Home Healthc Nurse. 2005;23(1):29-36.
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psnet.ahrq.gov/issue/developing-and-evaluating-trigger-response-system
August 29, 2018 - Study
Developing and evaluating a trigger response system.
Citation Text:
Cherry K, Martinek J, Esleck S, et al. Developing and Evaluating a Trigger Response System. The Joint Commission Journal on Quality and Patient Safety. 2016;35(6). doi:10.1016/s1553-7250(09)35047-3.
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psnet.ahrq.gov/issue/unintended-doses-radiotherapy-over-under-and-outside
August 27, 2009 - Commentary
Unintended doses in radiotherapy—over, under and outside?
Citation Text:
Eaton DJ, Byrne JP, Cosgrove VP, et al. Unintended doses in radiotherapy-over, under and outside? Br J Radiol. 2018;91(1084):20170863. doi:10.1259/bjr.20170863.
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psnet.ahrq.gov/issue/need-risk-profiling-patient-safety
August 08, 2010 - Commentary
The need for risk profiling in patient safety.
Citation Text:
Donaldson LJ, Noble DJ. The need for risk profiling in patient safety. J Patient Saf. 2010;6(3):125-7. doi:10.1097/PTS.0b013e3181ed73a3.
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psnet.ahrq.gov/issue/time-transparent-standards-quality-reporting-health-care-organizations
July 07, 2021 - Commentary
Time for transparent standards in quality reporting by health care organizations.
Citation Text:
Pronovost P, Wu AW, Austin M. Time for Transparent Standards in Quality Reporting by Health Care Organizations. JAMA. 2017;318(8):701-702. doi:10.1001/jama.2017.10124.
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psnet.ahrq.gov/issue/headline-grabbing-study-brings-attention-back-medical-errors
August 16, 2017 - Journal Article
Headline-grabbing study brings attention back to medical errors.
Citation Text:
Abbasi J. Headline-Grabbing Study Brings Attention Back to Medical Errors. JAMA. 2016;316(7):698-700. doi:10.1001/jama.2016.8073.
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psnet.ahrq.gov/issue/empowering-patient-safety-outreach-through-interprofessional-partnerships-educating-our
August 17, 2022 - Commentary
Empowering patient safety outreach through interprofessional partnerships: educating our communities.
Citation Text:
Walton L, Childs C, Egeland M, et al. Empowering Patient Safety Outreach Through Interprofessional Partnerships: Educating Our Communities. J Hosp Librariansh. …
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psnet.ahrq.gov/issue/effects-duty-napping-intern-sleep-time-and-fatigue
February 03, 2011 - Study
The effects of on-duty napping on intern sleep time and fatigue.
Citation Text:
Arora V, Dunphy C, Chang VY, et al. The effects of on-duty napping on intern sleep time and fatigue. Ann Intern Med. 2006;144(11):792-8.
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psnet.ahrq.gov/issue/improving-patient-safety-through-simulation-training-anesthesiology-where-are-we
October 13, 2018 - Review
Improving patient safety through simulation training in anesthesiology: where are we?
Citation Text:
Green M, Tariq R, Green P. Improving Patient Safety through Simulation Training in Anesthesiology: Where Are We? Anesthesiol Res Pract. 2016;2016:4237523. doi:10.1155/2016/4237523.…
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psnet.ahrq.gov/issue/diagnosis-reducing-errors-and-improving-quality
October 12, 2022 - Book/Report
Diagnosis: Reducing Errors and Improving Quality.
Citation Text:
Diagnosis: Reducing Errors and Improving Quality. Schiff G. Chapter In: Loscalzo J, Fauci A, Kasper D, et al, eds. Harrison's Principles of Internal Medicine, 21e. New York, NY: McGraw Hill; 2022
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psnet.ahrq.gov/issue/annotated-bibliography-understanding-ambulatory-care-practices-context-patient-safety-and
March 02, 2010 - Commentary
Annotated bibliography: an update to: "Understanding ambulatory care practices in the context of patient safety and quality improvement."
Citation Text:
Kumar PR, Nash DB. Annotated Bibliography: An Update to “Understanding Ambulatory Care Practices in the Context of Patient S…
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psnet.ahrq.gov/issue/agreement-between-patient-reported-symptoms-and-their-documentation-medical-record
November 09, 2022 - Study
Agreement between patient-reported symptoms and their documentation in the medical record.
Citation Text:
Pakhomov S, Jacobsen SJ, Chute CG, et al. Agreement between patient-reported symptoms and their documentation in the medical record. Am J Manag Care. 2008;14(8):530-539.
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psnet.ahrq.gov/issue/teamwork-operating-theatre-cohesion-or-confusion
July 26, 2011 - Study
Teamwork in the operating theatre: cohesion or confusion?
Citation Text:
Undre S, Sevdalis N, Healey A, et al. Teamwork in the operating theatre: cohesion or confusion? J Eval Clin Pract. 2006;12(2):182-9.
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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