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psnet.ahrq.gov/node/42880/psn-pdf
January 22, 2014 - Applying ethnography to the study of context in
healthcare quality and safety.
January 22, 2014
Leslie M, Paradis E, Gropper MA, et al. Applying ethnography to the study of context in healthcare quality
and safety. BMJ Qual Saf. 2014;23(2):99-105. doi:10.1136/bmjqs-2013-002335.
https://psnet.ahrq.gov/issue/applyin…
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psnet.ahrq.gov/node/60187/psn-pdf
April 01, 2020 - What are we doing when we double check?
April 1, 2020
Pfeiffer Y, Zimmermann C, Schwappach DLB. What are we doing when we double check? BMJ Qual Saf.
2020;29(7):536-540. doi:10.1136/bmjqs-2019-009680.
https://psnet.ahrq.gov/issue/what-are-we-doing-when-we-double-check
Double checking is one strategy for detecting …
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psnet.ahrq.gov/node/38764/psn-pdf
July 08, 2009 - Multidisciplinary obstetric simulated emergency
scenarios (MOSES): promoting patient safety in
obstetrics with teamwork-focused interprofessional
simulations.
July 8, 2009
Freeth D, Ayida G, Berridge EJ, et al. Multidisciplinary obstetric simulated emergency scenarios (MOSES):
promoting patient safety in obstetri…
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psnet.ahrq.gov/node/34660/psn-pdf
December 24, 2008 - Building a learning organization.
December 24, 2008
Garvin DA. Building a learning organization. Harv Bus Rev. 1993;71(4):78-91.
https://psnet.ahrq.gov/issue/building-learning-organization
Garvin, a Harvard Business School professor, postulates that for organizations to truly improve over time
and succeed, they ne…
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psnet.ahrq.gov/node/43430/psn-pdf
October 20, 2014 - Positive deviance: a different approach to achieving
patient safety.
October 20, 2014
Lawton R, Taylor N, Clay-Williams R, et al. Positive deviance: a different approach to achieving patient
safety. BMJ Qual Saf. 2014;23(11):880-3. doi:10.1136/bmjqs-2014-003115.
https://psnet.ahrq.gov/issue/positive-deviance-diffe…
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psnet.ahrq.gov/node/47387/psn-pdf
September 12, 2018 - Guideline implementation: team communication.
September 12, 2018
Link T. Guideline Implementation: Team Communication: 1.8 www.aornjournal.org/content/cme. AORN J.
2018;108(2):165-177. doi:10.1002/aorn.12300.
https://psnet.ahrq.gov/issue/guideline-implementation-team-communication
Although team development has rec…
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psnet.ahrq.gov/node/46333/psn-pdf
June 25, 2018 - High reliability leadership: a conceptual framework.
June 25, 2018
Martínez-Córcoles M. High reliability leadership: A conceptual framework. J Contingencies Crisis Manage.
2017;26(2):237-246. doi:10.1111/1468-5973.12187.
https://psnet.ahrq.gov/issue/high-reliability-leadership-conceptual-framework
Leadership engag…
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psnet.ahrq.gov/node/45837/psn-pdf
March 08, 2017 - Promoting civility in the OR: an ethical imperative.
March 8, 2017
Clark CM, Kenski D. Promoting Civility in the OR: An Ethical Imperative. AORN J. 2017;105(1):60-66.
doi:10.1016/j.aorn.2016.10.019.
https://psnet.ahrq.gov/issue/promoting-civility-or-ethical-imperative
The operating room is a complex environment th…
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psnet.ahrq.gov/node/43872/psn-pdf
January 28, 2015 - Technology and error-prevention strategies: why are we
still overlooking the IV room?
January 28, 2015
ISMP Medication Safety Alert! Acute Care Edition. January 15, 2015;20:1-4.
https://psnet.ahrq.gov/issue/technology-and-error-prevention-strategies-why-are-we-still-overlooking-iv-
room
This newsletter article di…
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psnet.ahrq.gov/node/39831/psn-pdf
September 15, 2010 - The importance of leadership in preventing
healthcare–associated infection: results of a multisite
qualitative study.
September 15, 2010
Saint S, Kowalski CP, Banaszak-Holl J, et al. The importance of leadership in preventing healthcare-
associated infection: results of a multisite qualitative study. Infect Contro…
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psnet.ahrq.gov/node/846167/psn-pdf
March 15, 2023 - Diagnostic stewardship to prevent diagnostic error.
March 15, 2023
Morgan DJ, Malani PN, Diekema DJ. Diagnostic stewardship to prevent diagnostic error. JAMA.
2023;329(15):1255-1256. doi:10.1001/jama.2023.1678.
https://psnet.ahrq.gov/issue/diagnostic-stewardship-prevent-diagnostic-error
The effective use of resour…
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psnet.ahrq.gov/node/866520/psn-pdf
August 14, 2024 - People are more error-prone after committing an error.
August 14, 2024
Adkins TJ, Zhang H, Lee TG. People are more error-prone after committing an error. Nat Commun.
2024;15(1):6422. doi:10.1038/s41467-024-50547-y.
https://psnet.ahrq.gov/issue/people-are-more-error-prone-after-committing-error
In order to improve …
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psnet.ahrq.gov/node/39481/psn-pdf
September 29, 2017 - The natural lifespan of a safety policy: violations and
system migration in anaesthesia.
September 29, 2017
Maurice G de S, Auroy Y, Vincent CA, et al. The natural lifespan of a safety policy: violations and system
migration in anaesthesia. Qual Saf Health Care. 2010;19(4):327-31. doi:10.1136/qshc.2008.029959.
htt…
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psnet.ahrq.gov/node/60997/psn-pdf
October 07, 2020 - ‘You’re going to release him when he was hurting
himself?’
October 7, 2020
Dahlberg B. Kaiser Health News. September 29, 2020.
https://psnet.ahrq.gov/issue/youre-going-release-him-when-he-was-hurting-himself
This story discusses failures related emergency psychiatric assessment, including premature discharge,
imp…
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psnet.ahrq.gov/node/40130/psn-pdf
January 12, 2011 - Patient safety culture: factors that influence clinician
involvement in patient safety behaviours.
January 12, 2011
Wakefield JG, McLaws M-L, Whitby M, et al. Patient safety culture: factors that influence clinician
involvement in patient safety behaviours. Qual Saf Health Care. 2010;19(6):585-91.
doi:10.1136/qshc…
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psnet.ahrq.gov/node/38593/psn-pdf
April 29, 2009 - The influence of standardisation and task load on team
coordination patterns during anaesthesia inductions.
April 29, 2009
Zala-Mezö E, Wacker J, Künzle B, et al. The influence of standardisation and task load on team
coordination patterns during anaesthesia inductions. Qual Saf Health Care. 2009;18(2):127-30; 1 p
…
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psnet.ahrq.gov/node/34661/psn-pdf
March 07, 2005 - Teaching smart people how to learn.
March 7, 2005
Argyris C. Harvard Business Review. 1991:69(May-June):99+.
https://psnet.ahrq.gov/issue/teaching-smart-people-learn
Argyris, a Harvard Business School professor, theorizes that companies and organizations must learn in
order to continually improve and succeed, but …
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psnet.ahrq.gov/node/61053/psn-pdf
October 21, 2020 - Some health workers suffering from addiction steal drugs
meant for patients.
October 21, 2020
Mann B. All Things Considered. National Public Radio. October 5, 2020.
https://psnet.ahrq.gov/issue/some-health-workers-suffering-addiction-steal-drugs-meant-patients
Clinicians are susceptible for medication mi…
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psnet.ahrq.gov/node/43084/psn-pdf
May 19, 2014 - How can the criminal law support the provision of quality
in healthcare?
May 19, 2014
Yeung K, Horder J. How can the criminal law support the provision of quality in healthcare? BMJ Qual Saf.
2014;23(6):519-24. doi:10.1136/bmjqs-2013-002688.
https://psnet.ahrq.gov/issue/how-can-criminal-law-support-provision-quali…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/references/tobaccogenrefs.pdf
January 01, 2010 - Evaluating primary care behavioral
counseling interventions: an evidence-based
approach. … Multiple behavioral risk factor interventions in
primary care. Summary of research evidence. … Nortriptyline and cognitive-behavioral therapy
in the treatment of cigarette smoking. … Short- and
long-term smoking cessation for three levels
of intensity of behavioral treatment. … Nicotine replacement and behavioral therapy
for smoking cessation in pregnancy.