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  1. Enhancing the effectiveness of team debriefings in medical simulation: more best practices. | PSNet

    psnet.ahrq.gov/issue/enhancing-effectiveness-team-debriefings-medical-simulation-more-best-practices
    March 17, 2021 - Commentary Enhancing the effectiveness of team debriefings in medical simulation: more best practices. Citation Text: Lyons R, Lazzara EH, Benishek LE, et al. Enhancing the effectiveness of team debriefings in medical simulation: more best practices. Jt Comm J Qual Patient Saf. 2015;41(3…

  2. The debrief imperative: building teaming competencies and team effectiveness. | PSNet

    psnet.ahrq.gov/issue/debrief-imperative-building-teaming-competencies-and-team-effectiveness
    December 16, 2020 - Commentary The debrief imperative: building teaming competencies and team effectiveness. Citation Text: Tannenbaum SI, Greilich PE. The debrief imperative: building teaming competencies and team effectiveness. BMJ Qual Saf. 2023;32(3):125-128. doi:10.1136/bmjqs-2022-015259. Copy Citati…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44709/psn-pdf
    November 18, 2016 - Lost information during the handover of critically injured trauma patients: a mixed-methods study. November 18, 2016 Zakrison TL, Rosenbloom B, McFarlan A, et al. Lost information during the handover of critically injured trauma patients: a mixed-methods study. BMJ Qual Saf. 2016;25(12):929-936. doi:10.1136/bmjqs-2…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43695/psn-pdf
    August 02, 2015 - The medical liability climate and prospects for reform. August 2, 2015 Mello MM, Studdert DM, Kachalia A. The medical liability climate and prospects for reform. JAMA. 2014;312(20):2146-55. doi:10.1001/jama.2014.10705. https://psnet.ahrq.gov/issue/medical-liability-climate-and-prospects-reform This review of natio…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49656/psn-pdf
    June 01, 2012 - Comanagement: Who's in Charge? June 1, 2012 Cheng HQ. Comanagement: Who's in Charge? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/comanagement-whos-charge The Case A 77-year-old man with a history of chronic obstructive pulmonary disease (COPD) was admitted with a left hip fracture to the orthopedic surg…

  6. Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx Spotlight When the Lytes Go Out: A Case of Inpatient Cardiac Arrest Source and Credits • This presentation is based on the September 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psne…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866055/psn-pdf
    May 29, 2024 - It was fully implemented in October 2020.2  Ascension recognized the importance of communicating about

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33580/psn-pdf
    April 01, 2022 - near misses, understanding care processes and weaknesses inherent in some systems, identifying and communicating

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854849/psn-pdf
    October 31, 2023 - yet a consensus on how to define high-quality notes, given that notes serve many purposes, including communicating

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74251/psn-pdf
    January 26, 2022 - Many hospitals, including ours, have a priority system for communicating radiologic finding and systems

  11. Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
    January 01, 2023 - tubes, hospitals must adopt protocols outlining routine practices for monitoring cuff pressures and communicating

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49684/psn-pdf
    May 01, 2013 - For example, a hierarchical organizational structure that discourages an employee from communicating

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49702/psn-pdf
    March 01, 2014 - errors occurring at one institution are uncovered at another, further complicating the process of communicating

  14. Nursing and Patient Safety | PSNet

    psnet.ahrq.gov/primer/nursing-and-patient-safety
    September 15, 2024 - near misses, understanding care processes and weaknesses inherent in some systems, identifying and communicating

  15. In Conversation With… Christine Cassel, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-christine-cassel-md
    February 26, 2025 - knew that the board was a multi-stakeholder board and the challenge of multiple and different sectors communicating

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837791/psn-pdf
    August 05, 2022 - could consist of clinicians overlooking abnormal, but non-life- threatening, test results and/or not communicating

  17. In Conversation with...Sorrel King | PSNet

    psnet.ahrq.gov/perspective/conversation-withsorrel-king
    March 01, 2007 - management team, and all these teams, yet there was never really one person who was leading people or communicating

  18. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness | PSNet

    psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
    February 01, 2014 - We need to work harder and smarter in communicating this information.

  19. Difficult Encounters: A CMO and CNO Respond | PSNet

    psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
    March 01, 2018 - SPOTLIGHT CASE Difficult Encounters: A CMO and CNO Respond Citation Text: Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33856/psn-pdf
    April 01, 2018 - Patient Safety During Hospital Discharge April 1, 2018 Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge Perspective Patients are admitted to the hospital in the United States 35 million times per year.(1)…
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