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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34719/psn-pdf
    December 23, 2008 - Learning from samples of one or fewer. December 23, 2008 March JG, Sproull LS, Tamuz M. Org Sci.1991;2:1-13. (reprinted in: Qual Saf Health Care 2003;12:465- 472.) https://psnet.ahrq.gov/issue/learning-samples-one-or-fewer Organizations learn from experience. However, learning from rare events is challenging becau…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60563/psn-pdf
    June 03, 2020 - ‘Last responders’ seek to expand postmortem COVID testing In unexplained deaths. June 3, 2020 Andrews M. Kaiser News Network. May 19, 2020. https://psnet.ahrq.gov/issue/last-responders-seek-expand-postmortem-covid-testing-unexplained-deaths Post-mortem examination is an important tool for determining if misdiagnos…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35111/psn-pdf
    April 06, 2011 - Patient safety features of clinical computer systems: questionnaire survey of GP views. April 6, 2011 Morris CJ, Savelyich BSP, Avery A, et al. Patient safety features of clinical computer systems: questionnaire survey of GP views. Qual Saf Health Care. 2005;14(3):164-8. https://psnet.ahrq.gov/issue/patient-safety…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34887/psn-pdf
    February 26, 2009 - Has the Leapfrog Group had an impact on the health care market? February 26, 2009 Galvin RS, Delbanco S, Milstein A, et al. Has the leapfrog group had an impact on the health care market? Health Aff (Millwood). 2005;24(1):228-33. https://psnet.ahrq.gov/issue/has-leapfrog-group-had-impact-health-care-market The Le…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836867/psn-pdf
    April 06, 2022 - Safer Dx Checklist: 10 High-Priority Practices for Diagnostic Excellence. April 6, 2022 Houston TX;  Baylor College of Medicine: 2022. https://psnet.ahrq.gov/issue/safer-dx-checklist-10-high-priority-practices-diagnostic-excellence Assessment can identify the current state of a process or program to reveal ar…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36041/psn-pdf
    June 21, 2006 - Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols. June 21, 2006 Rampersaud YR; Moro ER; Neary MA; White K; Lewis SJ; Massicotte EM; Fehlings MG. https://psnet.ahrq.gov/issue/intraoperative-adverse-…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43718/psn-pdf
    December 03, 2014 - Patient safety culture in nephrology nurse practice settings: initial findings. December 3, 2014 Ulrich B, Kear T. Nephrol Nurs J. 2014;41:459-476. https://psnet.ahrq.gov/issue/patient-safety-culture-nephrology-nurse-practice-settings-initial-findings This study utilized AHRQ patient safety culture surveys to asse…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866357/psn-pdf
    July 24, 2024 - People’s Experiences of Diagnosis. July 24, 2024 People’s Experiences Of Diagnosis. London, England: National Voices; June 2024. https://psnet.ahrq.gov/issue/peoples-experiences-diagnosis The discussion of diagnostic safety has expanded to include an effort to realize excellence. This report explores the diagnosti…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37564/psn-pdf
    June 12, 2008 - The medical emergency team system: a two hospital comparison. June 12, 2008 Young L, Donald M, Parr M, et al. The Medical Emergency Team system: a two hospital comparison. Resuscitation. 2008;77(2):180-8. doi:10.1016/j.resuscitation.2007.11.016. https://psnet.ahrq.gov/issue/medical-emergency-team-system-two-hospit…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36204/psn-pdf
    September 30, 2010 - Automated medication error studies with audit supplementation were effectively designed and analyzed by time series. September 30, 2010 Shuster JJ, Winterstein AG. Automated medication error studies with audit supplementation were effectively designed and analyzed by time series. J Clin Epidemiol. 2006;59(9). doi…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37376/psn-pdf
    March 28, 2012 - Duty hours restriction and their effect on resident education and academic departments: the American perspective. March 28, 2012 Swide CE, Kirsch JR. Duty hours restriction and their effect on resident education and academic departments: the American perspective. Curr Opin Anaesthesiol. 2007;20(6):580-4. https://…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36965/psn-pdf
    February 15, 2011 - Strategic work-arounds to accommodate new technology: the case of smart pumps in hospital care. February 15, 2011 McAlearney AS, Vrontos J, Schneider PJ, et al. Strategic Work-Arounds to Accommodate New Technology. J Patient Saf. 2008;3(2). doi:10.1097/01.jps.0000242987.93789.63. https://psnet.ahrq.gov/issue/strat…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39103/psn-pdf
    November 18, 2009 - Identifying organizational cultures that promote patient safety. November 18, 2009 Singer SJ, Falwell A, Gaba DM, et al. Identifying organizational cultures that promote patient safety. Health Care Manag Rev. 2009;34(4):300-311. doi:10.1097/HMR.0b013e3181afc10c. https://psnet.ahrq.gov/issue/identifying-organizatio…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840494/psn-pdf
    November 30, 2022 - Safety of anesthetic and perioperative medication practices. November 30, 2022 Meyer TA. Anesthesiology News. October 31, 2022. https://psnet.ahrq.gov/issue/safety-anesthetic-and-perioperative-medication-practices Medication use in the surgical environment is complex and high-risk. This article describes steps tow…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39973/psn-pdf
    January 04, 2011 - Residency training at a crossroads: duty-hour standards 2010. January 4, 2011 Volpp KG, Friedman W, Romano PS, et al. Residency training at a crossroads: duty-hour standards 2010. Ann Intern Med. 2010;153(12):826-8. doi:10.7326/0003-4819-153-12-201012210-00287. https://psnet.ahrq.gov/issue/residency-training-cross…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38701/psn-pdf
    June 28, 2011 - Selection of indicators for continuous monitoring of patient safety: recommendations of the project 'safety improvement for patients in Europe.'  June 28, 2011 Kristensen S, Mainz J, Bartels P. Selection of indicators for continuous monitoring of patient safety: recommendations of the project 'safety improvement f…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45241/psn-pdf
    October 31, 2023 - Hospital Harm Project. October 31, 2023 Canadian Institute for Health Information, Health Excellence Canada. https://psnet.ahrq.gov/issue/hospital-harm-project Reducing preventable harm associated with health care is a worldwide goal. This Canadian initiative developed a measure to track unintended harm in acute c…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43495/psn-pdf
    December 15, 2014 - Disruptive behaviors among physicians. December 15, 2014 Sanchez LT. Disruptive behaviors among physicians. JAMA. 2014;312(21):2209-2210. doi:10.1001/jama.2014.10218. https://psnet.ahrq.gov/issue/disruptive-behaviors-among-physicians This commentary spotlights concerns about physicians with disruptive behaviors an…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34618/psn-pdf
    July 28, 2013 - National Survey on Consumers' Experiences With Patient Safety and Quality Information. July 28, 2013 Washington DC: Kaiser Family Foundation, Agency for Healthcare Research and Quality, Harvard School of Public Health; 2004. https://psnet.ahrq.gov/issue/national-survey-consumers-experiences-patient-safety-and-qual…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39184/psn-pdf
    January 06, 2010 - Patient safety attitudes of paediatric trainee physicians. January 6, 2010 Parry G, Horowitz L, Goldmann D. Patient safety attitudes of paediatric trainee physicians. Qual Saf Health Care. 2009;18(6):462-6. doi:10.1136/qshc.2006.020230. https://psnet.ahrq.gov/issue/patient-safety-attitudes-paediatric-trainee-physic…
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