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psnet.ahrq.gov/web-mm/preventable-transfer-hospital
March 31, 2022 - Preventable Transfer to the Hospital
Citation Text:
Agrawal G, Kashkouli P, Bakerjian D. Preventable Transfer to the Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
May 16, 2022 - When the Meds Don’t Reach the Bed
Citation Text:
Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/print/pdf/node/866984
January 01, 2020 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Interdisciplinary teamwork
Curated Library
Foundations
Medical teamwork and the evolution of safety science: a critical review.
Neuhaus C, Lutnæs DE, Bergström J. Cogn Technol Work. 2020;22:13-27.
In this narrative review, the authors contr…
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psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning
December 22, 2018 - SPOTLIGHT CASE
Engaging Seriously Ill Older Patients in Advance Care Planning
Citation Text:
Heyland DK. Engaging Seriously Ill Older Patients in Advance Care Planning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. …
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psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
February 26, 2025 - Timing is a barrier, especially when relying on extramural funding. … The environment that we are working in right now is another barrier.
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psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
February 26, 2025 - Timing is a barrier, especially when relying on extramural funding. … The environment that we are working in right now is another barrier.
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psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - The subsequent error message represented a barrier designed to catch such discrepancies.
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psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy
July 01, 2008 - August 30, 2023
The neglected barrier to medication use: a systematic review of difficulties
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psnet.ahrq.gov/perspective/remote-patient-monitoring
March 15, 2023 - patients who may only have to travel a few miles across town, but even distance can be a significant barrier
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psnet.ahrq.gov/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-patient-monitoring
March 15, 2023 - patients who may only have to travel a few miles across town, but even distance can be a significant barrier
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psnet.ahrq.gov/web-mm/caution-interrupted
October 01, 2016 - Organizational silence: a barrier to change and development in a pluralistic world.
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psnet.ahrq.gov/primer/rapid-response-systems
July 18, 2024 - Rapid Response Systems
Citation Text:
Rapid Response Systems. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
September 15, 2024 - Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery
Citation Text:
Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/838082/psn-pdf
September 14, 2022 - Organizational factors that promote error reporting in
healthcare: a scoping review.
September 14, 2022
Wawersik D, Palaganas J. Organizational factors that promote error reporting in healthcare: a scoping
review. J Healthc Manag. 2022;67(4):283-301. doi:10.1097/jhm-d-21-00166.
https://psnet.ahrq.gov/issue/organiz…
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psnet.ahrq.gov/node/60762/psn-pdf
August 05, 2020 - Implementation and sustainability of a medication
reconciliation toolkit: a mixed methods evaluation.
August 5, 2020
Stolldorf DP, Mixon AS, Auerbach AD, et al. Implementation and sustainability of a medication
reconciliation toolkit: a mixed methods evaluation. Am J Health Syst Pharm. 2020;77(14):1135-1143.
doi:1…
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psnet.ahrq.gov/node/846170/psn-pdf
March 15, 2023 - Duplicate Therapies in Retail Pharmacy
March 15, 2023
Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
The Cases
Case 1: A middle-aged man with a past medical history of heart failure with reduced ejection f…
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psnet.ahrq.gov/node/837034/psn-pdf
May 04, 2022 - Understanding the link between burnout and sub-optimal
care: why should healthcare education be interested in
employee silence?
May 4, 2022
Montgomery A, Lainidi O. Understanding the link between burnout and sub-optimal care: why should
healthcare education be interested in employee silence? Front Psychiatry. 2022…
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psnet.ahrq.gov/node/50746/psn-pdf
December 18, 2019 - The influence of organizational culture, climate and
commitment on speaking up about medical errors.
December 18, 2019
Levine KJ, Carmody M, Silk KJ. The influence of organizational culture, climate and commitment on
speaking up about medical errors. J Nurs Manag. 2019;28(1):130-138. doi:10.1111/jonm.12906.
https:…
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psnet.ahrq.gov/node/42422/psn-pdf
November 18, 2013 - Resilient actions in the diagnostic process and system
performance.
November 18, 2013
Smith MW, Giardina TD, Murphy DR, et al. Resilient actions in the diagnostic process and system
performance. BMJ Qual Saf. 2013;22(12):1006-13. doi:10.1136/bmjqs-2012-001661.
https://psnet.ahrq.gov/issue/resilient-actions-diagnos…
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psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md
December 01, 2009 - Advances have been made, but there are still significant opportunities for improvement.( 2-4 ) Is the barrier … don't think that any individual intentionally starts out the day wanting to be either disruptive or a barrier