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psnet.ahrq.gov/node/41768/psn-pdf
March 11, 2013 - Science and patient safety.
March 11, 2013
Vincent CA. Science and patient safety. CMAJ. 2013;185(2):110-1. doi:10.1503/cmaj.120792.
https://psnet.ahrq.gov/issue/science-and-patient-safety
This commentary recommends a coordinated scientific research effort to analyze patient safety concerns
and potential improveme…
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psnet.ahrq.gov/issue/association-communication-between-hospital-based-physicians-and-primary-care-providers
September 09, 2013 - Study
Association of communication between hospital-based physicians and primary care providers with patient outcomes.
Citation Text:
Bell CM, Schnipper JL, Auerbach AD, et al. Association of communication between hospital-based physicians and primary care providers with patient out…
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psnet.ahrq.gov/issue/application-human-factors-analysis-and-classification-system-methodology-cardiovascular
January 06, 2012 - Study
Application of the human factors analysis and classification system methodology to the cardiovascular surgery operating room.
Citation Text:
Elbardissi AW, Wiegmann DA, Dearani JA, et al. Application of the human factors analysis and classification system methodology to the cardi…
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psnet.ahrq.gov/issue/adapting-new-technologies-operating-room
January 16, 2017 - Study
Classic
Adapting to new technologies in the operating room.
Citation Text:
Cook RI, Woods DD. Adapting to New Technology in the Operating Room. Hum Factors. 2006;38(4):593-613. doi:10.1518/001872096778827224.
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DOI Google …
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psnet.ahrq.gov/issue/inadequate-health-literacy-among-paid-caregivers-seniors
May 04, 2010 - Study
Inadequate health literacy among paid caregivers of seniors.
Citation Text:
Lindquist LA, Jain N, Tam K, et al. Inadequate health literacy among paid caregivers of seniors. J Gen Intern Med. 2011;26(5):474-9. doi:10.1007/s11606-010-1596-2.
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DOI …
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psnet.ahrq.gov/node/72611/psn-pdf
December 23, 2020 - Improving Diagnosis in Medicine Act of 2020.
December 23, 2020
116th Congress 2d session. December 10, 2020.
https://psnet.ahrq.gov/issue/improving-diagnosis-medicine-act-2020
The strengthening of diagnostic error research and processes can strategically ensure lasting diagnostic
improvement. The ‘‘Improving Diagn…
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psnet.ahrq.gov/node/47983/psn-pdf
May 01, 2019 - Health systems and hospitals in pursuit of high reliability.
May 1, 2019
Cheney C. HealthLeaders Media. April 17, 2019.
https://psnet.ahrq.gov/issue/health-systems-and-hospitals-pursuit-high-reliability
This news article describes how a 19-hospital health system successfully applied high reliability principles
to …
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psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
December 01, 2007 - in their ability to take in new information probably do need someone—whether you label that person a coordinator
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psnet.ahrq.gov/perspective/care-transitions
December 01, 2007 - in their ability to take in new information probably do need someone—whether you label that person a coordinator
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - Intubation Mishap
September 1, 2003
Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/intubation-mishap
Case Objectives
To understand and apply a structured method of human factors case analysis
To describe the key components of effective teamwork
To understand the imp…
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psnet.ahrq.gov/node/866966/psn-pdf
October 16, 2024 - Diagnostic Excellence in U.S. Rural Healthcare: A Call to
Action.
October 16, 2024
Ali KJ, Galvez NJ, Craig S, et al. Diagnostic Excellence In U.s. Rural Healthcare: A Call To Action.
Rockville, MD: Agency for Healthcare Research and Quality; September 2024. AHRQ Publication No. 24-
0010-9-EF
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/35171/psn-pdf
December 19, 2018 - Measuring Patient Safety.
December 19, 2018
Newhouse R, Poe S. Sudbury, MA: Jones and Bartlett Publishers; 2005. ISBN 9780763728410.
https://psnet.ahrq.gov/issue/measuring-patient-safety
This book provides nurses with the concepts and processes involved in improving patient safety. From
discussion of safety princi…
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psnet.ahrq.gov/node/851462/psn-pdf
July 19, 2023 - Broken Trust: Making Patient Safety More than Just a
Promise.
July 19, 2023
Manchester, UK: Parliamentary and Health Service Ombudsman; June 2023. ISBN: 9781528642446.
https://psnet.ahrq.gov/issue/broken-trust-making-patient-safety-more-just-promise
Lack of accountability for systemic contributions to failure degr…
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psnet.ahrq.gov/node/50568/psn-pdf
October 23, 2019 - Automation of the I-PASS tool to improve transitions of
care.
October 23, 2019
Skaret MM, Weaver TD, Humes RJ, et al. Automation of the I-PASS Tool to Improve Transitions of Care. J
Healthc Qual. 2019;41(5):274-280. doi:10.1097/JHQ.0000000000000174.
https://psnet.ahrq.gov/issue/automation-i-pass-tool-improve-trans…
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psnet.ahrq.gov/node/851059/psn-pdf
June 28, 2023 - Causes for medical errors in obstetrics and gynaecology.
June 28, 2023
Klemann D, Rijkx M, Mertens H, et al. Causes for medical errors in obstetrics and gynaecology. Healthcare
(Basel). 2023;11(11):1636. doi:10.3390/healthcare11111636.
https://psnet.ahrq.gov/issue/causes-medical-errors-obstetrics-and-gynaecology
R…
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psnet.ahrq.gov/node/50784/psn-pdf
January 08, 2020 - Improving Quality of Care and Patient Outcomes During
Care Transitions (R01).
January 8, 2020
Rockville, MD: Agency for Healthcare Research and Quality; December 6, 2019. PA-20-068.
https://psnet.ahrq.gov/issue/improving-quality-care-and-patient-outcomes-during-care-transitions-r01
Communication during patient tra…
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psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
November 08, 2013 - Diffusion of Responsibility Leads to Danger
Citation Text:
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/34626/psn-pdf
August 13, 2018 - National Patient Safety Agency (NPSA).
August 13, 2018
National Patient Safety Agency.
https://psnet.ahrq.gov/issue/national-patient-safety-agency-npsa
The National Patient Safety Agency was created in 2001 to coordinate efforts across the United Kingdom in
reporting and learning from mistakes and problems. In Apr…
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psnet.ahrq.gov/node/867097/psn-pdf
November 06, 2024 - Recommendations but no Action: Improving the
Effectiveness of Quality and Safety Recommendations in
Healthcare.
November 6, 2024
Recommendations But No Action: Improving The Effectiveness Of Quality And Safety Recommendations
In Healthcare. Dorset, UK: Health Services Safety Investigations Body; September 2024.
h…
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psnet.ahrq.gov/node/858167/psn-pdf
December 13, 2023 - A proposed approach to allegations of sexual boundary
violation in health care.
December 13, 2023
Cooper WO, Foster JJ, Hickson GB, et al. A proposed approach to allegations of sexual boundary violation
in health care. Jt Comm J Qual Patient Saf. 2023;49(12):671-679. doi:10.1016/j.jcjq.2023.08.006.
https://psnet.a…