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7661. Chapter 3. Description of Methods | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter3.html
      August 01, 2022 - recommended designing the system to facilitate access for consumers who may face language, literacy, or cultural … of the event for the individual harmed and family members, whether and how the event was disclosed, cultural

7662. What Have We Learned About Safe Inpatient Handovers? | PSNet
      psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
      March 01, 2011 - RW: Difficult because of cultural resistance or difficult because of logistics and the workload just … Development and testing of an objective structured clinical exam (OSCE) to assess socio-cultural

7663. Disposition of Comments Technical Brief 41: Evaluation of Mental Health Mobile Applications (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/mental-health-mobile-apps-disposition-of-comments.pdf
      May 20, 2022 - Cultural competence in framework does not fit into the existing guiding questions. … Cultural competence was not identified in the initial scope of work provided by AHRQ (including the

7664. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
      January 01, 2003 - The risk tree in Figure 1 illustrates the interrelationships between human errors, cultural or behavioral … Through this repetitive process, the interdisciplinary team arrived at an estimate for the local cultural

7665. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837593/psn-pdf
      June 29, 2022 - Adverse event reporting priorities: an integrative review. June 29, 2022 Falcone ML, Van Stee SK, Tokac U, et al. Adverse event reporting priorities: an integrative review. J Patient Saf. 2022;18(4):e727-e740. doi:10.1097/pts.0000000000000945. https://psnet.ahrq.gov/issue/adverse-event-reporting-priorities-integrat…

7666. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837192/psn-pdf
      May 25, 2022 - Declaration to Advance Patient Safety. May 25, 2022 National Steering Committee for Patient Safety. Boston, MA: Institute for Healthcare Improvement; May 2022. https://psnet.ahrq.gov/issue/declaration-advance-patient-safety Leadership commitment is crucial to attaining sustainable improvement in patient safety. Th…

7667. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836790/psn-pdf
      March 23, 2022 - Human Factors In Healthcare. March 23, 2022 Keebler JR, Salas E, Rosen MA, et al. eds. Hum Factors. 2022;64(1):5-258. https://psnet.ahrq.gov/issue/human-factors-healthcare Human factors concepts are central to improvement in high-risk industries and efforts are emerging to enfold them into health care organization…

7668. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40000/psn-pdf
      November 10, 2017 - Behind Human Error, Second Edition. November 10, 2017 Woods DD, Dekker S, Cook R, Johannesen L. Boca Raton, FL: CRC Press; 2017. ISBN: 9781317175537. https://psnet.ahrq.gov/issue/behind-human-error-second-edition "Human error," the authors of this book argue, is an inherently misleading term.  Drawing on the field …

7669. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40956/psn-pdf
      January 01, 2016 - Michigan Health & Hospital Association Keystone Obstetrics: a statewide collaborative for perinatal patient safety in Michigan. January 31, 2005 Simpson KR, Knox GE, Martin M, et al. Michigan Health & Hospital Association Keystone Obstetrics: A Statewide Collaborative for Perinatal Patient Safety in Michigan. Jt C…

7670. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60990/psn-pdf
      October 07, 2020 - Tiered daily huddles: the power of teamwork in managing large healthcare organisations. October 7, 2020 Mihaljevic T. Tiered daily huddles: the power of teamwork in managing large healthcare organisations. BMJ Qual Saf. 2020;29(12):1050-1052. doi:10.1136/bmjqs-2019-010575. https://psnet.ahrq.gov/issue/tiered-daily…

7671. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47944/psn-pdf
      April 17, 2019 - How to deliver safer and effective patient care: tips for team leaders and educators. April 17, 2019 Shah BJ. How to Deliver Safer and Effective Patient Care: Tips for Team Leaders and Educators. Gastroenterology. 2019;156(4):852-855. doi:10.1053/j.gastro.2019.02.017. https://psnet.ahrq.gov/issue/how-deliver-safer…

7672. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44656/psn-pdf
      November 11, 2015 - Making health care safer: what is the contribution of health psychology? November 11, 2015 Vincent CA, Wearden A, French DP. Making health care safer: What is the contribution of health psychology? Br J Health Psychol. 2015;20(4):681-7. doi:10.1111/bjhp.12166. https://psnet.ahrq.gov/issue/making-health-care-safer-…

7673. Technical Bundles Module | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/technical-bundles.html
      March 01, 2017 - Technical Bundles Module This module provides evidence-based recommendations, literature reviews, sample protocols, and other resources to help the team address the following topics: Daily Care Processes Early Mobility Low Tidal Volume Ventilation Overview of the AHRQ Safety Program for Mechanically…

7674. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838192/psn-pdf
      September 28, 2022 - When medical error becomes personal, activism becomes painful. September 28, 2022 Millenson M. Forbes. September 16, 2022. https://psnet.ahrq.gov/issue/when-medical-error-becomes-personal-activism-becomes-painful Unnecessary medication infusions indicate weaknesses in medication service processes. While no harm w…

7675. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842779/psn-pdf
      January 12, 2011 - Resilience Engineering in Practice: a Guidebook. January 12, 2011 Hollnagel E, Parie?s J, Woods DD et al eds. Farnham UK; Ashgate, 2011. ISBN: 9781472420749 https://psnet.ahrq.gov/issue/resilience-engineering-practice-guidebook Safety-critical industries rely on organizational aptitude to respond to disr…

7676. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/862614/psn-pdf
      February 14, 2024 - Systemic failures in nursing home care--a scoping study. February 14, 2024 Sturmberg JP, Gainsford L, Goodwin N, et al. Systemic failures in nursing home care—A scoping study. J Eval Clin Pract. 2024. doi:10.1111/jep.13961. https://psnet.ahrq.gov/issue/systemic-failures-nursing-home-care-scoping-study Nursing home…

7677. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60040/psn-pdf
      March 11, 2020 - Shifting the Mindset: A Closer Look at Hospital Complaints. March 11, 2020 Newcastle upon Tyne, UK: Healthwatch; January 2020. https://psnet.ahrq.gov/issue/shifting-mindset-closer-look-hospital-complaints Organizations need to do more than report and collect complaint data to realize improvements based on what is…

7678. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866358/psn-pdf
      July 24, 2024 - To improve health care, focus on fixing systems — not people. July 24, 2024 Mate KS, Clark J, Salvon-Harman J. To improve health care, focus on fixing systems — not people. Harvard Business Review. July 12, 2024; https://psnet.ahrq.gov/issue/improve-health-care-focus-fixing-systems-not-people While a focus on the…

7679. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836833/psn-pdf
      March 30, 2022 - As a nurse faces prison for a deadly error, her colleagues worry: could I be next? March 30, 2022 Kelman B. Kaiser Health News. March 22, 2022 https://psnet.ahrq.gov/issue/nurse-faces-prison-deadly-error-her-colleagues-worry-could-i-be-next Criminalization of medical mistakes typifies the blame-focused approach pa…

7680. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47951/psn-pdf
      April 24, 2019 - Safe medication management at ambulatory surgery centers. April 24, 2019 Ubaldi K. Safe Medication Management at Ambulatory Surgery Centers. AORN J. 2019;109(4):435-442. doi:10.1002/aorn.12635. https://psnet.ahrq.gov/issue/safe-medication-management-ambulatory-surgery-centers Safe medication use can be challengin…