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  1. Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st century. | PSNet

    psnet.ahrq.gov/issue/shepherding-change-how-market-healthcare-providers-and-public-policy-can-deliver-quality-care
    July 20, 2022 - Commentary Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st century. Citation Text: Kennedy P, Pronovost P. Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st…

  2. Imperfect practice makes perfect: error management training improves transfer of learning. | PSNet

    psnet.ahrq.gov/issue/imperfect-practice-makes-perfect-error-management-training-improves-transfer-learning
    May 19, 2019 - Study Imperfect practice makes perfect: error management training improves transfer of learning. Citation Text: Dyre L, Tabor A, Ringsted C, et al. Imperfect practice makes perfect: error management training improves transfer of learning. Med Educ. 2017;51(2):196-206. doi:10.1111/medu.13…

  3. Organizational learning: health care leaders need to design structures and processes that enhance collective learning. | PSNet

    psnet.ahrq.gov/issue/organizational-learning-health-care-leaders-need-design-structures-and-processes-enhance
    November 18, 2020 - Commentary Organizational learning: health care leaders need to design structures and processes that enhance collective learning. Citation Text: Bohmer RM, Edmondson AC. Organizational learning in health care. Health Forum J. 2001;44(2):32-35. Copy Citation Format: Google…

  4. Missed diagnosis of new-onset systolic heart failure at first presentation in children with no known heart disease. | PSNet

    psnet.ahrq.gov/issue/missed-diagnosis-new-onset-systolic-heart-failure-first-presentation-children-no-known-heart
    August 18, 2021 - Study Missed diagnosis of new-onset systolic heart failure at first presentation in children with no known heart disease. Citation Text: Puri K, Singh H, Denfield SW, et al. Missed diagnosis of new-onset systolic heart failure at first presentation in children with no known heart disease…

  5. Is oral chemotherapy prescription safe for patients? A cross-sectional survey. | PSNet

    psnet.ahrq.gov/issue/oral-chemotherapy-prescription-safe-patients-cross-sectional-survey
    May 18, 2022 - Study Is oral chemotherapy prescription safe for patients? A cross-sectional survey. Citation Text: Bourmaud A, Pacaut C, Melis A, et al. Is oral chemotherapy prescription safe for patients? A cross-sectional survey. Ann Oncol. 2014;25(2):500-504. doi:10.1093/annonc/mdt553. Copy Citati…

  6. Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV Series. | PSNet

    psnet.ahrq.gov/issue/final-report-prioritization-patient-safety-practices-new-rapid-review-or-rapid-response
    December 21, 2022 - Book/Report Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV Series. Citation Text: Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer …

  7. Should I report? A qualitative study of barriers to incident reporting among nurses working in nursing homes. | PSNet

    psnet.ahrq.gov/issue/should-i-report-qualitative-study-barriers-incident-reporting-among-nurses-working-nursing
    March 31, 2021 - Study Should I report? A qualitative study of barriers to incident reporting among nurses working in nursing homes. Citation Text: Prang IW, Jelsness-Jørgensen L-P. Should I report? A qualitative study of barriers to incident reporting among nurses working in nursing homes. Geriatr Nurs.…

  8. Employee silence in health care: charting new avenues for leadership and management. | PSNet

    psnet.ahrq.gov/issue/employee-silence-health-care-charting-new-avenues-leadership-and-management
    May 04, 2022 - Commentary Employee silence in health care: charting new avenues for leadership and management. Citation Text: Montgomery A, Lainidi O, Johnson J, et al. Employee silence in health care: Charting new avenues for leadership and management. Health Care Manage Rev. 2023;48(1):52-60. doi:10.…

  9. Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. | PSNet

    psnet.ahrq.gov/issue/enabling-learning-healthcare-system-automated-computer-protocols-produce-replicable-and
    September 23, 2020 - Commentary Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. Citation Text: Morris AH, Stagg B, Lanspa M, et al. Enabling a learning healthcare system with automated computer protocols that produce replicab…

  10. Association between parent comfort with English and adverse events among hospitalized children. | PSNet

    psnet.ahrq.gov/issue/association-between-parent-comfort-english-and-adverse-events-among-hospitalized-children
    June 29, 2022 - Study Association between parent comfort with English and adverse events among hospitalized children. Citation Text: Khan A, Yin HS, Brach C, et al. Association between parent comfort with English and adverse events among hospitalized children. JAMA Pediatr. 2020;174(12):e203215. doi:10.…

  11. Quality and safety implications of emergency department information systems. | PSNet

    psnet.ahrq.gov/issue/quality-and-safety-implications-emergency-department-information-systems
    November 30, 2012 - Commentary Quality and safety implications of emergency department information systems. Citation Text: Farley HL, Baumlin KM, Hamedani A, et al. Quality and safety implications of emergency department information systems. Ann Emerg Med. 2013;62(4):399-407. doi:10.1016/j.annemergmed.201…

  12. Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory. | PSNet

    psnet.ahrq.gov/issue/comparison-and-interpretation-urinalysis-performed-nephrologist-versus-hospital-based
    March 14, 2016 - Study Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory. Citation Text: Tsai JJ, Yeun JY, Kumar VA, et al. Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laborato…

  13. What became of the 'eyes and the ears'?: exploring the challenges to reporting poor quality of care among trainee medical staff. | PSNet

    psnet.ahrq.gov/issue/what-became-eyes-and-ears-exploring-challenges-reporting-poor-quality-care-among-trainee
    June 24, 2020 - Commentary What became of the 'eyes and the ears'?: exploring the challenges to reporting poor quality of care among trainee medical staff. Citation Text: Berry P. What became of the ‘eyes and the ears’?: exploring the challenges to reporting poor quality of care among trainee medical st…

  14. The critical incident technique. | PSNet

    psnet.ahrq.gov/issue/critical-incident-technique
    January 07, 2015 - Study Classic The critical incident technique. Citation Text: FLANAGAN JC. The critical incident technique. Psychol Bull. 1954;51(4):327-358. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

  15. One-stop diagnostic breast clinics: how often are breast cancers missed? | PSNet

    psnet.ahrq.gov/issue/one-stop-diagnostic-breast-clinics-how-often-are-breast-cancers-missed
    August 04, 2021 - Study One-stop diagnostic breast clinics: how often are breast cancers missed? Citation Text: Britton P, Duffy SW, Sinnatamby R, et al. One-stop diagnostic breast clinics: how often are breast cancers missed? Br J Cancer. 2009;100(12). doi:10.1038/sj.bjc.6605082. Copy Citation Fo…

  16. Physician perspectives on addressing anti-Black racism. | PSNet

    psnet.ahrq.gov/issue/physician-perspectives-addressing-anti-black-racism
    July 26, 2023 - Study Physician perspectives on addressing anti-Black racism. Citation Text: Brown CE, Marshall AR, Cueva KL, et al. Physician perspectives on addressing anti-Black racism. JAMA Netw Open. 2024;7(1):e2352818. doi:10.1001/jamanetworkopen.2023.52818. Copy Citation Format: DOI…

  17. How valid is the ICD-9-CM based AHRQ Patient Safety Indicator for postoperative venous thromboembolism? | PSNet

    psnet.ahrq.gov/issue/how-valid-icd-9-cm-based-ahrq-patient-safety-indicator-postoperative-venous-thromboembolism
    April 03, 2017 - Study How valid is the ICD-9-CM based AHRQ Patient Safety Indicator for postoperative venous thromboembolism? Citation Text: White RH, Sadeghi B, Tancredi DJ, et al. How Valid is the ICD-9-CM Based AHRQ Patient Safety Indicator for Postoperative Venous Thromboembolism? Med Care. 2009;4…

  18. Pediatric obesity and safety in inpatient settings: a systematic literature review. | PSNet

    psnet.ahrq.gov/issue/pediatric-obesity-and-safety-inpatient-settings-systematic-literature-review
    November 12, 2014 - Review Pediatric obesity and safety in inpatient settings: a systematic literature review. Citation Text: Halvorson EE, Irby MB, Skelton JA. Pediatric obesity and safety in inpatient settings: a systematic literature review. Clin Pediatr (Phila). 2014;53(10):975-87. doi:10.1177/000992281…

  19. Error in intensive care: psychological repercussions and defense mechanisms among health professionals. | PSNet

    psnet.ahrq.gov/issue/error-intensive-care-psychological-repercussions-and-defense-mechanisms-among-health
    November 29, 2023 - Study Error in intensive care: psychological repercussions and defense mechanisms among health professionals. Citation Text: Laurent A, Aubert L, Chahraoui K, et al. Error in intensive care: psychological repercussions and defense mechanisms among health professionals. Crit Care Med. 201…

  20. CHaMP: A model for building a center to support health care worker well-being after experiencing an adverse event. | PSNet

    psnet.ahrq.gov/issue/champ-model-building-center-support-health-care-worker-well-being-after-experiencing-adverse
    January 18, 2023 - Commentary CHaMP: A model for building a center to support health care worker well-being after experiencing an adverse event. Citation Text: McIntosh MS, Garvan C, Kalynych CJ, et al. CHaMP: A model for building a center to support health care worker well-being after experiencing an adve…
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