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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34642/psn-pdf
    June 24, 2015 - Drawing from experiences in cardiac surgery, the authors detail the process of capturing and examining … The authors also share lessons learned from exploring similar high- complexity industries.
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36199/psn-pdf
    March 28, 2011 - The authors hypothesize that this finding could reflect fatigue (as demonstrated in a prior simulation … Moreover, for most AEs, the authors could not determine whether patients were harmed or whether the
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34907/psn-pdf
    August 03, 2009 - weak associations between the effective interventions and their ratings of effectiveness, and the authors … The authors conclude with a number of suggestions for better translation of evidence into adopted practice
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35023/psn-pdf
    March 04, 2011 - The authors describe operational aspects of SASM and report on nearly 45,000 deaths reviewed in the … The authors conclude that voluntary mortality audits may lead to important changes in practice and focusing
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36017/psn-pdf
    June 14, 2006 - The authors describe the assumptions and consequences of control-based management and compare it to … Along with existing cultural barriers (eg, hierarchy, silos, and a "caste structure"), the authors argue
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34645/psn-pdf
    December 23, 2008 - issue/how-do-patients-want-physicians-handle-mistakes-survey-internal-medicine- patients-academic The authors … The authors conclude that open communication between patients and providers is important and may reduce
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35588/psn-pdf
    February 03, 2011 - The authors offer a series of explanations for these delays in important improvements and apply the … The authors argue that sustained change occurs only when these root causes receive appropriate exploration
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36025/psn-pdf
    March 28, 2011 - The authors begin with a general discussion about diagnostic errors before presenting a framework for … Using a case example, the authors illustrate how situational awareness can be applied to health care
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34886/psn-pdf
    February 03, 2011 - The authors also describe noted regional differences within European cities and report a number of factors … They authors call for greater regulatory measures and uniformity within the European Union to improve
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38662/psn-pdf
    April 12, 2011 - The authors identified two main groups of errors: action errors, errors of patient behavior such as failing … The authors suggest that further research should investigate how interactions among patients, clinicians
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34058/psn-pdf
    September 29, 2017 - The authors provide a framework for evaluating work of this nature and focus specifically on quantitative … The authors advocate for selecting an evaluation strategy that meets the needs and available resources
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36265/psn-pdf
    April 21, 2015 - The authors have previously argued that the current US tort system is ineffective at compensating injured … The authors describe how health courts would work in practice, and argue that such a system could improve
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34957/psn-pdf
    February 28, 2011 - The authors present six key recommendations. … The authors advocate for greater emphasis on teamwork, increased education about effective communication
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35617/psn-pdf
    January 01, 2016 - The authors provide a summary of their safe practice recommendations and share their reconciliation … Overall, the authors provide a practical, step-by-step experiential guide for institutions and individuals
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34796/psn-pdf
    November 18, 2015 - The authors examine four case studies to explore the financial and clinical implications of quality … The authors share the differing perspectives of the stakeholders to demonstrate how intimately tied
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35242/psn-pdf
    February 24, 2011 - The authors enrolled 228 patients hospitalized on an inpatient medical service and discovered that 8% … The authors conclude that engaging patients in the identification of medical errors may offer an additional
  17. effectivehealthcare.ahrq.gov/sites/default/files/related_files/pelvic-pain_disposition-comments.pdf
    January 01, 2012 - Comments on draft reviews and the authors’ responses to the comments are posted for public viewing on … I did think that the authors should be more critical in the section relating to comorbidities. … The authors have approached their topic with admirable thoroughness. … The authors get at this issue but could address this more in the discussion. … The authors should be commended for their synthesis and appraisal of the evidence.
  18. effectivehealthcare-admin.ahrq.gov/sites/default/files/related_files/pelvic-pain_disposition-comments.pdf
    January 01, 2012 - Comments on draft reviews and the authors’ responses to the comments are posted for public viewing on … I did think that the authors should be more critical in the section relating to comorbidities. … The authors have approached their topic with admirable thoroughness. … The authors get at this issue but could address this more in the discussion. … The authors should be commended for their synthesis and appraisal of the evidence.
  19. effectivehealthcare.ahrq.gov/sites/default/files/related_files/advanced-care-decision-aids_disposition-comments.pdf
    July 29, 2014 - At the conclusion of the public comment period, authors use the commentators’ submissions and comments … Comments on draft reviews and the authors’ responses to the comments are posted for public viewing on … The tables below include the responses by the authors of the review to each comment that was submitted … The authors should consider clearly defining what they consider ACP to be. … Peer Reviewer #3 Findings The authors’ findings are nicely organized and described.
  20. effectivehealthcare-admin.ahrq.gov/sites/default/files/related_files/advanced-care-decision-aids_disposition-comments.pdf
    July 29, 2014 - At the conclusion of the public comment period, authors use the commentators’ submissions and comments … Comments on draft reviews and the authors’ responses to the comments are posted for public viewing on … The tables below include the responses by the authors of the review to each comment that was submitted … The authors should consider clearly defining what they consider ACP to be. … Peer Reviewer #3 Findings The authors’ findings are nicely organized and described.