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psnet.ahrq.gov/node/866562/psn-pdf
January 01, 2025 - Understanding the challenges and successes of
implementing 'hybrid' interventions in healthcare
settings: findings from a process evaluation of a patient
involvement trial.
August 21, 2024
Hampton S, Murray J, Lawton R, et al. Understanding the challenges and successes of implementing
‘hybrid’ interventions in he…
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psnet.ahrq.gov/node/866113/psn-pdf
June 12, 2024 - Reducing the risk of delayed colorectal cancer diagnoses
through an ambulatory safety net collaborative.
June 12, 2024
Moyal-Smith R, Elam M, Boulanger J, et al. Reducing the risk of delayed colorectal cancer diagnoses
through an ambulatory safety net collaborative. Jt Comm J Qual Patient Saf. 2024;50(10):690-699.
…
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psnet.ahrq.gov/node/865806/psn-pdf
May 08, 2024 - Entangled in complexity: an ethnographic study of
organizational adaptability and safe care transitions for
patients with complex care needs.
May 8, 2024
Hedqvist A?T, Praetorius G, Ekstedt M, et al. Entangled in complexity: an ethnographic study of
organizational adaptability and safe care transitions for patient…
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psnet.ahrq.gov/node/60858/psn-pdf
August 26, 2020 - When the Meds Don’t Reach the Bed
August 26, 2020
Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
The Case
A 69-year-old man with cognitive impairment and marginal housing was admitted for acute exacerbation of
chronic obs…
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psnet.ahrq.gov/node/72650/psn-pdf
January 20, 2021 - A roadmap to advance patient safety in ambulatory care.
January 20, 2021
Singh H, Carayon P. A roadmap to advance patient safety in ambulatory care. JAMA. 2020;324(24):2481-
2482. doi:10.1001/jama.2020.18551.
https://psnet.ahrq.gov/issue/roadmap-advance-patient-safety-ambulatory-care
Preventable harm, such as diag…
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psnet.ahrq.gov/node/840475/psn-pdf
November 30, 2022 - Complexity and challenges of the clinical diagnosis and
management of Long COVID.
November 30, 2022
O’Hare AM, Vig EK, Iwashyna TJ, et al. Complexity and challenges of the clinical diagnosis and
management of Long COVID. JAMA Netw Open. 2022;5(11):e2240332.
doi:10.1001/jamanetworkopen.2022.40332.
https://psnet.ah…
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psnet.ahrq.gov/node/73714/psn-pdf
September 15, 2021 - Evaluation of Quality, Safety, and Value in Veterans
Health Administration Facilities, FY 2020.
September 15, 2021
Washington, DC: Veterans Affairs Office of Inspector General; August 26, 2021. Report No. 21-01502-240.
https://psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-f…
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psnet.ahrq.gov/node/836836/psn-pdf
March 30, 2022 - Deficiencies after the New Electronic Health Record Go-
Live at the Mann-Grandstaff VA Medical Center in
Spokane, WA.
March 30, 2022
Washington, DC: VA Office of Inspector General; March 17, 2022.
https://psnet.ahrq.gov/issue/deficiencies-after-new-electronic-health-record-go-live-mann-grandstaff-va-
medical-cent…
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psnet.ahrq.gov/node/840487/psn-pdf
November 30, 2022 - Interprofessional team collaboration and work
environment health in 68 US intensive care units.
November 30, 2022
Pun BT, Jun J, Tan A, et al. Interprofessional team collaboration and work environment health in 68 US
intensive care units. Am J Crit Care. 2022;31(6):443-451. doi:10.4037/ajcc2022546.
https://psnet.a…
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psnet.ahrq.gov/node/845347/psn-pdf
March 01, 2023 - Race differences in a malpractice event database in a
large healthcare system.
March 1, 2023
Thomas AD, Pandit C, Krevat S. Race differences in a malpractice event database in a large healthcare
system. J Patient Saf. 2023;19(2):67-70. doi:10.1097/pts.0000000000001090.
https://psnet.ahrq.gov/issue/race-differences…
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psnet.ahrq.gov/node/72643/psn-pdf
January 13, 2021 - Ockenden Report. Emerging Fndings and
Recommendations from the Independent Review of
Maternity Services at the Shrewsbury and Telford
Hospital NHS Trust.
January 13, 2021
London UK: Crown Copyright; December 10, 2020. ISBN: 9781528623049.
https://psnet.ahrq.gov/issue/ockenden-report-emerging-fndings-a…
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psnet.ahrq.gov/node/72654/psn-pdf
January 20, 2020 - What is an ethically informed approach to managing
patient safety risk during discharge planning?
January 20, 2020
West JC. What Is an Ethically Informed Approach to Managing Patient Safety Risk During Discharge
Planning? AMA J Ethics. 2020;22(!1):e919-e923. doi:10.1001/amajethics.2020.919.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/73857/psn-pdf
September 22, 2021 - A theoretical model of flow disruptions for the anesthesia
team during cardiovascular surgery.
September 22, 2021
Boquet A, Cohen T, Diljohn F, et al. A theoretical model of flow disruptions for the anesthesia team during
cardiovascular surgery. J Patient Saf. 2021;17(6):e534-e539. doi:10.1097/pts.0000000000000406.…
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psnet.ahrq.gov/node/36226/psn-pdf
August 30, 2006 - Framework for a High Performance Health System for the
United States.
August 30, 2006
Mongan JJ. New York, NY; The Commonwealth Fund: 2006.
https://psnet.ahrq.gov/issue/framework-high-performance-health-system-united-states
This report calls for providing "safe, well-coordinated, accessible, and efficient" care th…
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psnet.ahrq.gov/node/45466/psn-pdf
September 07, 2016 - Building a highway to quality health care.
September 7, 2016
Watson S, Pronovost P. Building a Highway to Quality Health Care. J Patient Saf. 2016;12(3):165-6.
doi:10.1097/PTS.0000000000000074.
https://psnet.ahrq.gov/issue/building-highway-quality-health-care
Substantial progress has been made in improving health …
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psnet.ahrq.gov/node/47132/psn-pdf
June 28, 2018 - National Steering Committee for Patient Safety.
June 28, 2018
Agency for Healthcare Research and Quality and the Institute for Healthcare Improvement.
https://psnet.ahrq.gov/issue/national-steering-committee-patient-safety
Preventable patient harm is a global public health concern. This announcement highlights a ne…
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psnet.ahrq.gov/node/38125/psn-pdf
January 11, 2017 - 2008 John M. Eisenberg Patient Safety and Quality
Awards.
January 11, 2017
Jt Comm J Qual Patient Saf. 2008;34(12):691-712.
https://psnet.ahrq.gov/issue/2008-john-m-eisenberg-patient-safety-and-quality-awards
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in
improving…
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psnet.ahrq.gov/node/853969/psn-pdf
September 27, 2023 - Perceptions of chief clinical information officers on the
state of electronic health records systems interoperability
in NHS England: a qualitative interview study.
September 27, 2023
Li E, Lounsbury O, Clarke J, et al. Perceptions of chief clinical information officers on the state of electronic
health records sy…
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psnet.ahrq.gov/node/852750/psn-pdf
August 23, 2023 - Cognitive biases and moral characteristics of healthcare
workers and their treatment approach for persons with
advanced dementia in acute care settings.
August 23, 2023
Erel M, Marcus E-L, DeKeyser Ganz F. Cognitive biases and moral characteristics of healthcare workers
and their treatment approach for persons wit…
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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…