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2581. Kaiser Permanente's performance improvement system, part 4: creating a learning organization. | PSNet
      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…

2582. Vital Signs: Core Metrics for Health and Health Care Progress. | PSNet
      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…

2583. SBAR: a shared mental model for improving communication between clinicians. | PSNet
      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. Copy Citation Format: …

2584. Failure mode and effects analysis: too little for too much? | PSNet
      psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-too-little-too-much
      November 25, 2009 - Commentary Failure mode and effects analysis: too little for too much? Citation Text: Franklin BD, Shebl NA, Barber N. Failure mode and effects analysis: too little for too much? BMJ Qual Saf. 2012;21(7):607-11. doi:10.1136/bmjqs-2011-000723. Copy Citation Format: DOI Goo…

2585. Bipartisan Consensus: The Public Wants Well-Rested Medical Residents to Help Ensure Safe Patient Care. | PSNet
      psnet.ahrq.gov/issue/bipartisan-consensus-public-wants-well-rested-medical-residents-help-ensure-safe-patient-care
      July 06, 2011 - Book/Report Bipartisan Consensus: The Public Wants Well-Rested Medical Residents to Help Ensure Safe Patient Care. Citation Text: Bipartisan Consensus: The Public Wants Well-Rested Medical Residents to Help Ensure Safe Patient Care. Almashat S, Carome M, Wolfe S, Landrigan CP, Czeisler C…

2586. Should patients have a role in patient safety? A safety engineering view. | PSNet
      psnet.ahrq.gov/issue/should-patients-have-role-patient-safety-safety-engineering-view
      June 10, 2009 - Commentary Should patients have a role in patient safety? A safety engineering view. Citation Text: Lyons M. Should patients have a role in patient safety? A safety engineering view. Qual Saf Health Care. 2007;16(2):140-2. Copy Citation Format: Google Scholar PubMed BibTe…

2587. IV push medications survey results—part 1 and part 2. | PSNet
      psnet.ahrq.gov/issue/iv-push-medications-survey-results-part-1-and-part-2
      December 12, 2018 - Newspaper/Magazine Article IV push medications survey results—part 1 and part 2. Citation Text: IV push medications survey results—part 1 and part 2. ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5. Copy Citation Save …

2588. Recommendations for using the Revised Safer Dx instrument to help measure and improve diagnostic safety. | PSNet
      psnet.ahrq.gov/issue/recommendations-using-revised-safer-dx-instrument-help-measure-and-improve-diagnostic-safety
      August 07, 2019 - Commentary Recommendations for using the Revised Safer Dx instrument to help measure and improve diagnostic safety. Citation Text: Singh H, Khanna A, Spitzmueller C, et al. Recommendations for using the Revised Safer Dx Instrument to help measure and improve diagnostic safety. Diagnosis …

2589. Mirror, Mirror on the Wall: An Update on the Quality of American Health Care Through the Patient's Lens. | PSNet
      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…

2590. Supplement on Deepening our Understanding of Quality in Australia (DUQuA). | PSNet
      psnet.ahrq.gov/issue/supplement-deepening-our-understanding-quality-australia-duqua
      February 04, 2009 - Special or Theme Issue Supplement on Deepening our Understanding of Quality in Australia (DUQuA). Citation Text: Supplement on Deepening our Understanding of Quality in Australia (DUQuA). Int J Qual Health Care. 2020;32(Supp1):1-105. Copy Citation Save Save t…

2591. The creation and impact of a dedicated section on quality and patient safety in a clinical academic department. | PSNet
      psnet.ahrq.gov/issue/creation-and-impact-dedicated-section-quality-and-patient-safety-clinical-academic-department
      May 28, 2008 - Commentary The creation and impact of a dedicated section on quality and patient safety in a clinical academic department. Citation Text: Boudreaux AM, Vetter TR. The Creation and Impact of a Dedicated Section on Quality and Patient Safety in a Clinical Academic Department. Academic Medi…

2592. Drawing boundaries: the difficulty in defining clinical reasoning. | PSNet
      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…

2593. Teaching about diagnostic errors through virtual patient cases: a pilot exploration. | PSNet
      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…

2594. A checklist to improve patient safety in interventional radiology. | PSNet
      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. Cop…

2595. Measurement of ambulatory medication errors in children: a scoping review. | PSNet
      psnet.ahrq.gov/issue/measurement-ambulatory-medication-errors-children-scoping-review
      February 07, 2024 - Review Measurement of ambulatory medication errors in children: a scoping review. Citation Text: Rickey L, Auger K, Britto MT, et al. Measurement of ambulatory medication errors in children: a scoping review. Pediatrics. 2023;152(6):e2023061281. doi:10.1542/peds.2023-061281. Copy Citat…

2596. Teaching but not learning: how medical residency programs handle errors. | PSNet
      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. Copy Citation Format: DOI Go…

2597. Managing clinical failure: a complex adaptive system perspective. | PSNet
      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. Copy Citation Format: …

2598. A simulation-based approach to training in heuristic clinical decision-making. | PSNet
      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. Copy Citation…

2599. The impact of declining clinical autopsy: need for revised healthcare policy. | PSNet
      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. Copy…

2600. Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data. | PSNet
      psnet.ahrq.gov/issue/developing-indicators-inpatient-adverse-drug-events-through-nonlinear-analysis-using
      December 23, 2011 - Study Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data. Citation Text: Nebeker JR, Yarnold PR, Soltysik RC, et al. Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data. Med…