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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/blaming-learning-re-framing-organisational-learning-adverse-incidents
October 05, 2022 - Study
From blaming to learning: re-framing organisational learning from adverse incidents.
Citation Text:
Gray D, Williams S. From blaming to learning: re‐framing organisational learning from adverse incidents. Learn Org. 2011;18(6):438-453. doi:10.1108/09696471111171295.
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psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm
June 21, 2016 - Book/Report
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.
Citation Text:
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient Safety Foundation; 2015.
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psnet.ahrq.gov/issue/apology-laws-and-malpractice-liability-what-have-we-learned
March 18, 2020 - Commentary
Apology laws and malpractice liability: what have we learned?
Citation Text:
Fields AC, Mello MM, Kachalia A. Apology laws and malpractice liability: what have we learned? BMJ Qual Saf. 2021;30(1):64-67. doi:10.1136/bmjqs-2020-010955.
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psnet.ahrq.gov/issue/interrelationship-isolation-precautions-and-adverse-events-acute-care-facility
September 24, 2010 - Study
The interrelationship of isolation precautions and adverse events in an acute care facility.
Citation Text:
Spence MR, McQuaid M. The interrelationship of isolation precautions and adverse events in an acute care facility. Am J Infect Control. 2011;39(2):154-155. doi:10.1016/j.aj…
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psnet.ahrq.gov/issue/nurse-staffing-levels-and-patient-reported-missed-nursing-care
September 27, 2017 - Study
Nurse staffing levels and patient-reported missed nursing care.
Citation Text:
Dabney BW, Kalisch BJ. Nurse Staffing Levels and Patient-Reported Missed Nursing Care. J Nurs Care Qual. 2015;30(4):306-12. doi:10.1097/NCQ.0000000000000123.
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psnet.ahrq.gov/issue/problem-never-events
July 12, 2023 - Commentary
The problem with 'never events'.
Citation Text:
Zaslow J, Fortier J, Garber G. The problem with ‘never events’. BMJ Qual Saf. 2024;33(9):613-616. doi:10.1136/bmjqs-2023-016981.
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psnet.ahrq.gov/issue/hospital-performance-trends-national-quality-measures-and-association-joint-commission
September 20, 2011 - Study
Hospital performance trends on national quality measures and the association with Joint Commission accreditation.
Citation Text:
Schmaltz SP, Williams SC, Chassin MR, et al. Hospital performance trends on national quality measures and the association with joint commission accre…
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psnet.ahrq.gov/issue/nurse-health-work-environment-presenteeism-and-patient-safety
December 14, 2016 - Study
Nurse health, work environment, presenteeism and patient safety.
Citation Text:
Rainbow JG, Drake DA, Steege LM. Nurse health, work environment, presenteeism and patient safety. West J Nurs Res. 2020;42(5):332-339. doi:10.1177/0193945919863409.
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psnet.ahrq.gov/issue/learning-how-learn-compliance-patient-safety-alerts-nhs
September 01, 2021 - Government Resource
Learning how to learn: compliance with patient safety alerts in the NHS.
Citation Text:
Learning how to learn: compliance with patient safety alerts in the NHS. Donaldson L. Chapter in: On the State of Public Health: Annual Report of the Chief Medical Officer. L…
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psnet.ahrq.gov/issue/limits-checklists-handoff-and-narrative-thinking
July 01, 2017 - Commentary
The limits of checklists: handoff and narrative thinking.
Citation Text:
Hilligoss B, Moffatt-Bruce SD. The limits of checklists: handoff and narrative thinking. BMJ Qual Saf. 2014;23(7):528-33. doi:10.1136/bmjqs-2013-002705.
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psnet.ahrq.gov/issue/operating-management-system-high-reliability-leadership-accountability-learning-and
July 01, 2016 - Commentary
Operating management system for high reliability: leadership, accountability, learning and innovation in healthcare.
Citation Text:
Day RM, Demski RJ, Pronovost PJ, et al. Operating management system for high reliability: Leadership, accountability, learning and innovation in …
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psnet.ahrq.gov/issue/health-literacy-past-present-and-future-workshop-summary
December 17, 2014 - Meeting/Conference Proceedings
Health Literacy: Past, Present, and Future: Workshop Summary.
Citation Text:
Health Literacy: Past, Present, and Future: Workshop Summary. Alper J; Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of Medicine. …
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psnet.ahrq.gov/issue/towards-high-reliability-organising-healthcare-strategy-building-organisational-capacity
January 06, 2016 - Commentary
Towards high-reliability organising in healthcare: a strategy for building organisational capacity.
Citation Text:
Aboumatar HJ, Weaver SJ, Rees D, et al. Towards high-reliability organising in healthcare: a strategy for building organisational capacity. BMJ Qual Saf. 2017;26(…
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psnet.ahrq.gov/issue/adverse-events-hospitals-patients-point-view
December 29, 2014 - Review
Adverse events in hospitals: the patient's point of view.
Citation Text:
Guijarro M, Andrés JMA, Mira JJ, et al. Adverse events in hospitals: the patient's point of view. Qual Saf Health Care. 2010;19(2):144-7. doi:10.1136/qshc.2007.025585.
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psnet.ahrq.gov/issue/real-malady-marcel-proust-and-what-it-reveals-about-diagnostic-errors-medicine
September 27, 2022 - Commentary
The real malady of Marcel Proust and what it reveals about diagnostic errors in medicine.
Citation Text:
Douglas Y. The real malady of Marcel Proust and what it reveals about diagnostic errors in medicine. Med Hypotheses. 2016;90:14-8. doi:10.1016/j.mehy.2016.02.024.
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psnet.ahrq.gov/issue/burnout-among-health-care-professionals-call-explore-and-address-underrecognized-threat-safe
November 11, 2020 - Book/Report
Burnout Among Health Care Professionals. A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care.
Citation Text:
Burnout Among Health Care Professionals. A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care. Dyrbye …
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psnet.ahrq.gov/issue/action-planning-tool-ahrq-surveys-patient-safety-culture
February 12, 2019 - Toolkit
Action Planning Tool for the AHRQ Surveys on Patient Safety Culture.
Citation Text:
Action Planning Tool for the AHRQ Surveys on Patient Safety Culture. Yount N, Edelman S, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; November 2022. AHRQ Publication …
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psnet.ahrq.gov/issue/nursing-2006-patient-safety-survey-report
March 01, 2023 - Study
Nursing 2006 Patient-safety survey report.
Citation Text:
Manno M, Hogan P, Heberlein V, et al. Nursing 2006. Patient-safety survey report. Nursing (Brux). 2006;36(5):54-64.
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psnet.ahrq.gov/issue/bending-patient-safety-curve-how-much-can-ai-help
March 31, 2021 - Commentary
Bending the patient safety curve: how much can AI help?
Citation Text:
Classen DC, Longhurst CA, Thomas EJ. Bending the patient safety curve: how much can AI help? NPJ Digit Med. 2023;6(1):2. doi:10.1038/s41746-022-00731-5.
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