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psnet.ahrq.gov/node/49834/psn-pdf
July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound
and Patient Safety
July 1, 2018
Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet].
2018.
https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
Case Objectives
Unders…
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psnet.ahrq.gov/issue/evaluation-interprofessional-team-training-program-improve-use-patient-safety-strategies
May 18, 2022 - Study
Evaluation of an interprofessional team training program to improve the use of patient safety strategies among healthcare professions students.
Citation Text:
Evaluation of an interprofessional team training program to improve the use of patient safety strategies among healthcare p…
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psnet.ahrq.gov/issue/implementing-patient-safety-and-quality-improvement-dermatology
September 30, 2015 - Commentary
Implementing patient safety and quality improvement in dermatology.
Citation Text:
Implementing patient safety and quality improvement in dermatology. Marsch A, Khodosh R, Porter M, et al. J Am Acad Dermatol. 2023;89(4):641-54; 57-67.
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psnet.ahrq.gov/issue/understanding-and-responding-adverse-events
July 19, 2019 - Commentary
Classic
Understanding and responding to adverse events.
Citation Text:
Vincent CA. Understanding and Responding to Adverse Events. New Engl J Med. 2003;348(11):1051-1056. doi:10.1056/nejmhpr020760.
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psnet.ahrq.gov/issue/creating-integrated-patient-safety-team
January 04, 2017 - Commentary
Classic
Creating an integrated patient safety team.
Citation Text:
Gandhi TK, Graydon-Baker E, Barnes JN, et al. Creating an integrated patient safety team. Jt Comm J Qual Saf. 2003;29(8):383-90.
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psnet.ahrq.gov/issue/kaiser-permanentes-performance-improvement-system-part-4-creating-learning-organization
July 19, 2023 - Commentary
Kaiser Permanente's performance improvement system, part 4: creating a learning organization.
Citation Text:
Schilling L, Dearing JW, Staley P, et al. Kaiser Permanente's performance improvement system, Part 4: Creating a learning organization. Jt Comm J Qual Patient Saf. 2011…
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psnet.ahrq.gov/issue/vital-signs-core-metrics-health-and-health-care-progress
November 24, 2021 - Book/Report
Vital Signs: Core Metrics for Health and Health Care Progress.
Citation Text:
Vital Signs: Core Metrics for Health and Health Care Progress. Blumenthal D, Malphrus E, McGinnis JM, eds. Committee on Core Metrics for Better Health at Lower Cost, Institute of Medicine. Washingto…
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psnet.ahrq.gov/issue/patient-engagement-patient-safety-why-what-and-how-patient-engagement-improving-patient
July 15, 2020 - Book/Report
Patient Engagement for Patient Safety: The Why, What, and How of Patient Engagement for Improving Patient Safety.
Citation Text:
Patient Engagement for Patient Safety: The Why, What, and How of Patient Engagement for Improving Patient Safety. Kendir C, Fujisawa R, Brito Ferna…
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psnet.ahrq.gov/issue/sbar-shared-mental-model-improving-communication-between-clinicians
January 02, 2017 - Study
SBAR: a shared mental model for improving communication between clinicians.
Citation Text:
Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf. 2006;32(3):167-75.
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psnet.ahrq.gov/issue/drawing-boundaries-difficulty-defining-clinical-reasoning
June 26, 2019 - Commentary
Emerging Classic
Drawing boundaries: the difficulty in defining clinical reasoning.
Citation Text:
Young M, Thomas A, Lubarsky S, et al. Drawing Boundaries: The Difficulty in Defining Clinical Reasoning. Acad Med. 2018;93(7):990-995. doi:10.1097/ACM.0…
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psnet.ahrq.gov/issue/teaching-about-diagnostic-errors-through-virtual-patient-cases-pilot-exploration
September 18, 2013 - Study
Teaching about diagnostic errors through virtual patient cases: a pilot exploration.
Citation Text:
Geha R, Trowbridge RL, Dhaliwal G, et al. Teaching about diagnostic errors through virtual patient cases: a pilot exploration. Diagnosis (Berl). 2018;5(4):223-227. doi:10.1515/dx-201…
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psnet.ahrq.gov/issue/checklist-improve-patient-safety-interventional-radiology
September 20, 2011 - Study
A checklist to improve patient safety in interventional radiology.
Citation Text:
Koetser ICJ, de Vries EN, van Delden OM, et al. A checklist to improve patient safety in interventional radiology. Cardiovasc Intervent Radiol. 2013;36(2):312-9. doi:10.1007/s00270-012-0395-z.
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psnet.ahrq.gov/issue/teaching-not-learning-how-medical-residency-programs-handle-errors
December 18, 2008 - Study
Teaching but not learning: how medical residency programs handle errors.
Citation Text:
Hoff T, Pohl H, Bartfield J. Teaching but not learning: how medical residency programs handle errors. J Organ Behav. 2006;27(7). doi:10.1002/job.395.
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psnet.ahrq.gov/issue/managing-clinical-failure-complex-adaptive-system-perspective
August 13, 2014 - Study
Managing clinical failure: a complex adaptive system perspective.
Citation Text:
Matthews JI, Thomas PT. Managing clinical failure: a complex adaptive system perspective. Int J Health Care Qual Assur. 2007;20(3):184-194. doi:10.1108/09526860710743336.
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psnet.ahrq.gov/issue/report-6-managing-risk-and-minimising-mistakes-services-children-and-families
June 13, 2012 - Book/Report
Report 6: Managing Risk and Minimising Mistakes in Services to Children and Families.
Citation Text:
Report 6: Managing Risk and Minimising Mistakes in Services to Children and Families. Bostock L, Bairstow S, Fish S, et al. London, UK: Social Care Institute for Excellenc…
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psnet.ahrq.gov/issue/simulation-based-approach-training-heuristic-clinical-decision-making
January 31, 2024 - Study
A simulation-based approach to training in heuristic clinical decision-making.
Citation Text:
Altabbaa G, Raven AD, Laberge J. A simulation-based approach to training in heuristic clinical decision-making. Diagnosis (Berl). 2019;6(2):91-99. doi:10.1515/dx-2018-0084.
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psnet.ahrq.gov/issue/impact-declining-clinical-autopsy-need-revised-healthcare-policy
February 14, 2018 - Review
The impact of declining clinical autopsy: need for revised healthcare policy.
Citation Text:
Xiao J, Krueger GRF, Buja M, et al. The impact of declining clinical autopsy: need for revised healthcare policy. Am J Med Sci. 2009;337(1):41-6. doi:10.1097/MAJ.0b013e318184ce2b.
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psnet.ahrq.gov/issue/post-operative-mortality-missed-care-and-nurse-staffing-nine-countries-cross-sectional-study
December 12, 2014 - June 22, 2022
Factors associated with missed nursing care and nurse-assessed quality
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psnet.ahrq.gov/issue/safety-attitudes-questionnaire-psychometric-properties-benchmarking-data-and-emerging
June 16, 2011 - nursing homes: variance of six patient safety climate factor scores across nursing homes and wards—assessed
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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