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psnet.ahrq.gov/print/pdf/node/845971
January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Value and Patient Safety
Curated Library
Foundations
Safety is the preservation of value.
Vandeskog B. J Safety Res. 2024;89:105-115.
Safety is at the heart of safety science, and yet “safety” lacks a consensus definition among safety
resea…
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psnet.ahrq.gov/node/44562/psn-pdf
April 13, 2016 - Undermining and bullying in surgical training: a review
and recommendations by the Association of Surgeons in
Training.
April 13, 2016
Wild JRL, Ferguson HJM, McDermott FD, et al. Undermining and bullying in surgical training: a review and
recommendations by the Association of Surgeons in Training. Int J Surg. 201…
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psnet.ahrq.gov/node/837759/psn-pdf
January 01, 2023 - Employee silence in health care: charting new avenues
for leadership and management.
August 3, 2022
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:10.1097/hmr.0000000000000349.
https://ps…
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psnet.ahrq.gov/node/61029/psn-pdf
October 14, 2020 - A doctor gave me an inept diagnosis for a neurological
problem. I should know: I’m a neurologist.
October 14, 2020
Horowitz SH. Washington Post. October 4, 2020.
https://psnet.ahrq.gov/issue/doctor-gave-me-inept-diagnosis-neurological-problem-i-should-know-im-
neurologist
The harm of misdiagnosis can be exte…
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psnet.ahrq.gov/node/867530/psn-pdf
January 15, 2025 - Experiences of nurses speaking up in healthcare settings:
a qualitative metasynthesis.
January 15, 2025
Lee E, De Gagne J C, Randall P S, et al. Experiences of nurses speaking up in healthcare settings: a
qualitative metasynthesis. J Adv Nurs. 2024;Epub Nov 4. doi:10.1111/jan.16592.
https://psnet.ahrq.gov/issue/ex…
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psnet.ahrq.gov/node/838133/psn-pdf
January 01, 2023 - Nurse managers' leadership, patient safety, and quality of
care: a systematic review.
September 21, 2022
Lee SE, Hyunjie L, Sang S. Nurse managers' leadership, patient safety, and quality of care: a systematic
review. West J Nurs Res. 2023;45(2):176-185. doi:10.1177/01939459221114079.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/837666/psn-pdf
July 13, 2022 - Developing and aligning a safety event taxonomy for
inpatient psychiatry.
July 13, 2022
Barnes T, Fontaine T, Bautista C, et al. Developing and aligning a safety event taxonomy for inpatient
psychiatry. J Patient Saf. 2022;18(4):e704-e713. doi:10.1097/pts.0000000000000935.
https://psnet.ahrq.gov/issue/developing-a…
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psnet.ahrq.gov/node/46487/psn-pdf
May 16, 2018 - High Reliability for a Highly Unreliable World: Preparing
for Code Blue Through Daily Operations in Healthcare.
May 16, 2018
van Stralen D, Byrum SL, Inozu B. North Charleston, SC: CreateSpace Publishing; 2018. ISBN:
1974506371.
https://psnet.ahrq.gov/issue/high-reliability-highly-unreliable-world-preparing-code-b…
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psnet.ahrq.gov/node/47375/psn-pdf
November 02, 2018 - Ethical duty of health care systems to address interfacility
medical error discovery.
November 2, 2018
Antunez AG, Shuman AG, Jagsi R, et al. Ethical Duty of Health Care Systems to Address Interfacility
Medical Error Discovery. J Am Coll Surg. 2018;227(5):543-547. doi:10.1016/j.jamcollsurg.2018.08.184.
https://psn…
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psnet.ahrq.gov/node/60525/psn-pdf
May 27, 2020 - Public sector organizational failure: a study of collective
denial in the UK national health service.
May 27, 2020
Hendy J, Tucker DA. Public sector organizational failure: a study of collective denial in the UK national
health service. J Bus Ethics. 2020;2021;172:691–706. doi:10.1007/s10551-020-04517-1.
https://p…
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psnet.ahrq.gov/node/43108/psn-pdf
September 28, 2023 - Maryland Hospital Patient Safety Program Annual Report.
September 28, 2023
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene.
https://psnet.ahrq.gov/issue/maryland-hospital-patient-safety-program-annual-report
This annual report summarizes never events in Maryland hospit…
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psnet.ahrq.gov/node/866114/psn-pdf
June 12, 2024 - Influence of external assessment on quality and safety in
surgery: a qualitative study of surgeons' perspectives.
June 12, 2024
Øyri SF, Wiig S, Tjomsland O. Influence of external assessment on quality and safety in surgery: a
qualitative study of surgeons’ perspectives. BMJ Open Qual. 2024;13(2):e002672. doi:10.11…
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psnet.ahrq.gov/node/851917/psn-pdf
January 01, 2024 - Incivility in healthcare: the impact of poor
communication.
August 2, 2023
Guppy JH, Widlund H, Munro R, et al. Incivility in healthcare: the impact of poor communication. BMJ Lead.
2024;8(1):83-87. doi:10.1136/leader-2022-000717.
https://psnet.ahrq.gov/issue/incivility-healthcare-impact-poor-communication
Incivi…
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www.ahrq.gov/teamstepps-program/evidence-base/nursing.html
June 01, 2023 - TeamSTEPPS Research/Evidence Base: Nursing
Creating a safe health care culture: Teaching communication skills and strategies. Nurse Educ . 2018;43(5):241. Epub 2018/08/24. doi: 10.1097/NNE.0000000000000522. PMID: 30138225.
Fukuta D, Iitsuka M. Nontechnical skills training and patient safety in undergraduate …
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psnet.ahrq.gov/node/36559/psn-pdf
July 14, 2010 - Description and evaluation of an interprofessional patient
safety course for health professions and related sciences
students.
July 14, 2010
Galt KA, Paschal KA, O'Brien RL, et al. Description and Evaluation of an Interprofessional Patient Safety
Course for Health Professions and Related Sciences Students. J Patie…
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psnet.ahrq.gov/node/50932/psn-pdf
February 26, 2020 - Clinician-directed performance improvement: moving
beyond externally mandated metrics.
February 26, 2020
Goitein L. Clinician-directed performance improvement: moving beyond externally mandated metrics.
Health Aff (Millwood). 2020;39(2). doi:10.1377/hlthaff.2019.00505.
https://psnet.ahrq.gov/issue/clinician-direct…
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psnet.ahrq.gov/node/61032/psn-pdf
October 14, 2020 - System Governance Towards Improved Patient Safety:
Key Functions, Approaches and Pathways to
Implementation.
October 14, 2020
Auraaen A, Saar K, Klazinga N for the Organisation for Economic Co-operation and Development. OECD
Publishing, Paris, France; 2020. OECD Health Working Papers, No. 120.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/853074/psn-pdf
February 06, 2024 - Patient Experience, Patient Safety, and Provider Well-
Being: Associations and Paths for Quality Improvement.
February 6, 2024
Rockville, MD: Agency for Healthcare Research and Quality; January 2024. AHRQ Publication no.
24-0030.
https://psnet.ahrq.gov/issue/patient-experience-patient-safety-and-provider-well…
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psnet.ahrq.gov/node/72777/psn-pdf
January 01, 2022 - The effect of health care professional disruptive behavior
on patient care: a systematic review.
February 24, 2021
Hicks S, Stavropoulou C. The effect of health care professional disruptive behavior on patient care: a
systematic review. J Patient Saf. 2022;18(2):138-143. doi:10.1097/pts.0000000000000805.
https://p…
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psnet.ahrq.gov/node/45456/psn-pdf
October 27, 2016 - On the relationship between safety climate and
occupational burnout in healthcare organizations.
October 27, 2016
Zarei E, Khakzad N, Reniers G, et al. On the relationship between safety climate and occupational burnout
in healthcare organizations. Saf Sci. 2016;89:1-10. doi:10.1016/j.ssci.2016.05.011.
https://psn…