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psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
February 26, 2025 - Cross-cutting these are culture, values, and equity, which we believe need to be embedded in everything … recommendations centered on four priority areas to build the foundation needed to advance patient safety: culture … learning and improvements in patient safety happen when learning health systems with a strong safety culture … components for creating and sustaining a successful learning health system include a strong safety culture
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psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
February 26, 2025 - recommendations centered on four priority areas to build the foundation needed to advance patient safety: culture … learning and improvements in patient safety happen when learning health systems with a strong safety culture … components for creating and sustaining a successful learning health system include a strong safety culture … Cross-cutting these are culture, values, and equity, which we believe need to be embedded in everything
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psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 2023 - Workplace
culture and human resource availability are common barriers to best practices. … • Numerous barriers to reporting exist including fear of consequences, a culture of
blame, perception … errors in a user-friendly and non-punitive
manner are needed, as are clear reporting guidelines and cultures … The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors
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psnet.ahrq.gov/node/33863/psn-pdf
August 01, 2018 - Some other countries do more simulation, but there's a fundamental
cultural belief that's still hard … Contrast that with nuclear power, where a safety culture is imposed in part by the regulators and in
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psnet.ahrq.gov/node/49402/psn-pdf
June 01, 2003 - At that time, a single blood culture grew vancomycin-resistant Enterococcus faecium (VRE), as
did a … A repeat blood
culture grew VRE, which necessitated removal and re-placement of yet another central … are clinically stable without any clear focus of infection usually are not harmed by
waiting until culture … This is also true if a patient was pre-treated with antibiotics, which
may render the culture results … If a bacterial infection is
identified, the culture and susceptibility data should be used to narrow
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psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
March 01, 2005 - Results from the original wound culture revealed CA-MRSA resistant to clindamycin. … In addition, an early follow-up visit would have provided an opportunity to review culture results and
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psnet.ahrq.gov/web-mm/x-ray-flip
August 10, 2019 - Culture at work in aviation and medicine. National, organizational and professional influences.
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psnet.ahrq.gov/node/49629/psn-pdf
June 01, 2011 - Gaining buy-in and successfully implementing read-backs is also easier when there is an organizational
culture
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psnet.ahrq.gov/issue/limits-checklists-handoff-and-narrative-thinking
July 01, 2017 - Commentary
The limits of checklists: handoff and narrative thinking.
Citation Text:
Hilligoss B, Moffatt-Bruce SD. The limits of checklists: handoff and narrative thinking. BMJ Qual Saf. 2014;23(7):528-33. doi:10.1136/bmjqs-2013-002705.
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DOI Google Scho…
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psnet.ahrq.gov/issue/liquid-medication-dosing-errors-hispanic-parents-role-health-literacy-and-english-proficiency
December 14, 2016 - Study
Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency.
Citation Text:
Harris LM, Dreyer BP, Mendelsohn A, et al. Liquid Medication Dosing Errors by Hispanic Parents: Role of Health Literacy and English Proficiency. Acad Pediatr. 2017;1…
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psnet.ahrq.gov/issue/high-performance-work-systems-health-care-management-part-1-and-part-2
March 22, 2017 - Special or Theme Issue
High-Performance Work Systems in Health Care Management: Parts 1-5.
Citation Text:
High-Performance Work Systems in Health Care Management: Parts 1-5. Garman AN, McAlearney AS, Harrison MI, et al. Health Care Manag Rev. 2011-2020.
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psnet.ahrq.gov/issue/implementing-strategies-prevent-home-medication-administration-errors-children-medical
March 14, 2022 - Commentary
Implementing strategies to prevent home medication administration errors in children with medical complexity.
Citation Text:
Shaikh U, Kim JM, Yin SH. Implementing strategies to prevent home medication administration errors in children with medical complexity. Clin Pediatr (Ph…
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psnet.ahrq.gov/issue/ensuring-competency-and-safety-when-onboarding-newly-hired-professional-staff
February 22, 2023 - Newspaper/Magazine Article
Ensuring competency and safety when onboarding newly hired professional staff.
Citation Text:
Ensuring competency and safety when onboarding newly hired professional staff. ISMP Medication Safety Alert! Acute care edition. April 20, 2023;28(8):1-4; May 4, 2023;…
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psnet.ahrq.gov/issue/artificial-intelligence-health-care-benefits-and-challenges-machine-learning-technologies
October 12, 2022 - Book/Report
Artificial Intelligence in Health Care: Benefits and Challenges of Machine Learning Technologies for Medical Diagnostics.
Citation Text:
Artificial Intelligence in Health Care: Benefits and Challenges of Machine Learning Technologies for Medical Diagnostics. Washington DC: Un…
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psnet.ahrq.gov/issue/inpatient-suicide-preventing-common-sentinel-event
May 28, 2015 - Review
Inpatient suicide: preventing a common sentinel event.
Citation Text:
Tishler CL, Reiss NS. Inpatient suicide: preventing a common sentinel event. Gen Hosp Psychiatry. 2009;31(2):103-9. doi:10.1016/j.genhosppsych.2008.09.007.
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DOI Google Scholar …
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psnet.ahrq.gov/issue/using-electronic-prescribing-system-ensure-accurate-medication-lists-large-multidisciplinary
August 28, 2017 - Study
Using an electronic prescribing system to ensure accurate medication lists in a large multidisciplinary medical group.
Citation Text:
Stock R, Scott J, Gurtel S. Using an electronic prescribing system to ensure accurate medication lists in a large multidisciplinary medical group. J…
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psnet.ahrq.gov/issue/collaborating-or-selling-patients-conceptual-framework-emergency-department-inpatient-handoff
December 21, 2017 - Commentary
Collaborating—or "selling" patients? A conceptual framework for emergency department-to-inpatient handoff negotiations.
Citation Text:
Hilligoss B, Mansfield JA, Patterson ES, et al. Collaborating-or "Selling" Patients? A Conceptual Framework for Emergency Department-to-Inpati…
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psnet.ahrq.gov/issue/va-health-care-selected-credentialing-requirements-seven-medical-facilities-met-aspect
July 05, 2006 - Government Resource
VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileging Process Needs Improvement.
Citation Text:
VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileg…
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psnet.ahrq.gov/issue/americas-hospitals-improving-quality-and-safety-joint-commissions-annual-report-2016
November 10, 2016 - Book/Report
America's Hospitals: Improving Quality and Safety—The Joint Commission's Annual Report 2016.
Citation Text:
America's Hospitals: Improving Quality and Safety—The Joint Commission's Annual Report 2016. Oakbrook Terrace, IL: The Joint Commission; November 2016.
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psnet.ahrq.gov/issue/patient-physician-medical-assistant-and-office-visit-factors-associated-medication-list
June 28, 2017 - February 17, 2017
Differing perceptions of safety culture across job roles in the ambulatory … setting: analysis of the AHRQ Medical Office Survey on Patient Safety Culture. … January 8, 2018
What patients think doctors know: beliefs about provider knowledge as