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psnet.ahrq.gov/issue/error-reporting-organizations
May 24, 2006 - Commentary
Error reporting in organizations.
Citation Text:
Error reporting in organizations. Zhao B; Olivera F. Acad Manag Rev. 2006;31(4):1012-1030.
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psnet.ahrq.gov/issue/ehealth-safety-impact-ict-patient-safety-and-risk-management
June 18, 2013 - Book/Report
eHealth for Safety: Impact of ICT on Patient Safety and Risk Management.
Citation Text:
eHealth for Safety: Impact of ICT on Patient Safety and Risk Management. European Commission Information Society and Media. October 2007
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psnet.ahrq.gov/issue/pc-standards-maternal-safety
September 06, 2017 - Newspaper/Magazine Article
PC standards for maternal safety.
Citation Text:
PC standards for maternal safety. The Joint Commission. R3 Report. August 21, 2019;24:1-6.
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psnet.ahrq.gov/issue/gift-failure-new-approaches-analyzing-and-learning-events-and-near-misses
August 07, 2019 - Special or Theme Issue
The Gift of Failure: New Approaches to Analyzing and Learning from Events and Near-Misses.
Citation Text:
The Gift of Failure: New Approaches to Analyzing and Learning from Events and Near-Misses. Fahlbruch B, Carroll JS, eds. Safety Sci. 2011;49(1):1-106  …
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psnet.ahrq.gov/issue/advances-patient-safety-research-implementation
December 24, 2008 - Government Resource
Classic
Advances in Patient Safety: From Research to Implementation.
Citation Text:
Advances in Patient Safety: From Research to Implementation. Henriksen K, Battles JB, Marks ES, et al, eds. Rockville, MD: Agency for Healthcare Research and …
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psnet.ahrq.gov/issue/framework-effective-board-governance-health-system-quality
January 20, 2016 - Book/Report
Framework for Effective Board Governance of Health System Quality.
Citation Text:
Framework for Effective Board Governance of Health System Quality. Daley Ullem E, Gandhi TK, Mate K, et al. IHI White Paper. Boston, MA: Institute for Healthcare Improvement; 2018.
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psnet.ahrq.gov/issue/becoming-high-reliability-organization-operational-advice-hospital-leaders
January 10, 2018 - Book/Report
Becoming a High Reliability Organization: Operational Advice for Hospital Leaders.
Citation Text:
Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Hines S, Luna K, Lofthus J, et al. Rockville, MD: Agency for Healthcare Research and Quality; F…
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psnet.ahrq.gov/issue/contemporary-view-medication-related-harm-new-paradigm
July 20, 2012 - Tools/Toolkit
Contemporary View of Medication-Related Harm. A New Paradigm.
Citation Text:
Contemporary View of Medication-Related Harm. A New Paradigm. National Coordinating Council for Medication Error Reporting and Prevention; NCCMERP.
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psnet.ahrq.gov/issue/national-center-patient-safety-ncps
March 27, 2005 - Multi-use Website
National Center for Patient Safety (NCPS).
Citation Text:
National Center for Patient Safety (NCPS). Department of Veterans Affairs. 24 Frank Lloyd Wright Drive, M2100, Post Office Box 486, Ann Arbor, MI 48106-0486. Phone: (734) 930-5890.
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psnet.ahrq.gov/issue/special-section-human-factors-and-ergonomics-operating-room-contributions-advance-surgical
September 01, 2018 - Special or Theme Issue
Special Section on Human Factors and Ergonomics in the Operating Room: Contributions That Advance Surgical Practice.
Citation Text:
Special Section on Human Factors and Ergonomics in the Operating Room: Contributions That Advance Surgical Practice. Hallbeck MS, Paq…
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psnet.ahrq.gov/issue/patient-safety-investigating-and-reporting-serious-clinical-incidents
November 10, 2017 - Book/Report
Patient Safety: Investigating and Reporting Serious Clinical Incidents.
Citation Text:
Patient Safety: Investigating and Reporting Serious Clinical Incidents. Kelsey R. CRC Press: Boca Raton, FL; 2017. ISBN: 9781498781169.
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psnet.ahrq.gov/issue/monitoring-diagnostic-process-inpatient-neurology-service
November 03, 2015 - Study
Monitoring the diagnostic process on an inpatient neurology service.
Citation Text:
Dhand A, Bucelli R, Varadhachary A, et al. Monitoring the Diagnostic Process on an Inpatient Neurology Service. Neurohospitalist. 2017;7(3):132-136. doi:10.1177/1941874416677681.
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psnet.ahrq.gov/issue/diagnostic-excellence-age-friendly-health-systems-dxex-afhs-seed-grant-program-improving
September 16, 2020 - Grant Announcement
Diagnostic Excellence– Age-Friendly Health Systems (DxEx–AFHS) Seed Grant Program Improving Diagnosis for Older Adults.
Citation Text:
Diagnostic Excellence– Age-Friendly Health Systems (DxEx–AFHS) Seed Grant Program Improving Diagnosis for Older Adults. Boston, MA: In…
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psnet.ahrq.gov/issue/advancing-safety-acute-pain-management
January 08, 2020 - Book/Report
Advancing the Safety of Acute Pain Management.
Citation Text:
Advancing the Safety of Acute Pain Management. Boston, MA: Institute for Healthcare Improvement; 2019.
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psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx
Spotlight
When the Indications for Drug
Administration Blur
Source and Credits
• This presentation is based on the June 2020 AHRQ
WebM&M Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: Julia Munsch,…
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psnet.ahrq.gov/node/33582/psn-pdf
September 15, 2024 - Detection of Safety Hazards
September 15, 2024
Detection of Safety Hazards. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/detection-safety-hazards
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient s…
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psnet.ahrq.gov/primer/detection-safety-hazards
March 30, 2022 - Detection of Safety Hazards
Citation Text:
Detection of Safety Hazards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
May 01, 2009 - Spotlight Case July 2008
Spotlight Case
Delirium or Dementia?
Source and Credits
This presentation is based on the May 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: James L. Rudolph, MD, SM
Editor, AHRQ WebM&M: Robert Wachter, MD
Sp…
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psnet.ahrq.gov/node/33827/psn-pdf
February 01, 2017 - While the quality of teamwork is not directly assessed in new payment models (although it
is undoubtedly … related to many of the outcomes that are assessed), that may well change.
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psnet.ahrq.gov/issue/why-patient-summaries-electronic-health-records-do-not-provide-cognitive-support-necessary
January 18, 2013 - January 18, 2013
The effect of hospital electronic health record adoption on nurse-assessed