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psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
November 26, 2019 - In addition to patient safety programs and the development of patient safety culture, we also tie in … February 21, 2020
Perspectives on Safety
Safety Culture
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - Perspective
What We've Learned About Leveraging Leadership and Culture … Perspective
Our Maturing Understanding of Safety Culture
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psnet.ahrq.gov/node/49847/psn-pdf
November 01, 2018 - Written Signout: It Only Works If You Use The Right One
November 1, 2018
Lewis K, Rosenbluth G. Written Signout: It Only Works If You Use The Right One. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/written-signout-it-only-works-if-you-use-right-one
The Case
A 75-year-old man was hospitalized due to a stro…
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - Implementing system changes in processes of care requires attention to inter-professional culture differences … determine whether the devices under consideration are likely to be helpful at that site, given that site’s culture
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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - Blood cultures were positive for E. coli, and appropriate antibiotic therapy was initiated. … of intraventricular gentamycin with resolution of ventriculitis as documented by negative E. coli cultures
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psnet.ahrq.gov/web-mm/forgotten-med
July 01, 2006 - The physician ordered stat blood cultures, electrolytes, and a head CT scan. … Custom documentation is common for higher-risk nursing tasks, such as documenting patient-controlled
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psnet.ahrq.gov/issue/national-survey-assessing-number-records-allowed-open-electronic-health-records-hospitals-and
May 29, 2019 - Study
A national survey assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites.
Citation Text:
Adelman JS, Berger MA, Rai A, et al. A national survey assessing the number of records allowed open in electronic health records at hospital…
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psnet.ahrq.gov/issue/weekend-effect-hospital-mortality-ischemic-and-hemorrhagic-stroke-us-rural-and-urban
January 19, 2022 - Study
Weekend effect on in-hospital mortality for ischemic and hemorrhagic stroke in US rural and urban hospitals.
Citation Text:
Mekonnen B, Wang G, Rajbhandari-Thapa J, et al. Weekend effect on in-hospital mortality for ischemic and hemorrhagic stroke in US rural and urban hospitals. J…
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psnet.ahrq.gov/issue/relationship-between-patients-perception-care-and-measures-hospital-quality-and-safety
February 13, 2019 - Study
Classic
The relationship between patients' perception of care and measures of hospital quality and safety.
Citation Text:
Isaac T, Zaslavsky AM, Cleary PD, et al. The relationship between patients' perception of care and measures of hospital quality and …
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psnet.ahrq.gov/issue/health-economic-evaluation-infection-prevention-and-control-program-are-quality-and-patient
June 02, 2021 - Study
Health economic evaluation of an infection prevention and control program: are quality and patient safety programs worth the investment?
Citation Text:
Raschka S, Dempster L, Bryce E. Health economic evaluation of an infection prevention and control program: are quality and patien…
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psnet.ahrq.gov/issue/health-disparities-impact-health-disparities-and-treatment-decision-making-biases-cancer
October 14, 2020 - Commentary
Health disparities: impact of health disparities and treatment decision-making biases on cancer adverse effects among black cancer survivors.
Citation Text:
Vo J, Gillman A, Mitchell K, et al. Health disparities: impact of health disparities and treatment decision-making biase…
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psnet.ahrq.gov/node/49767/psn-pdf
August 21, 2016 - Falling Between the Cracks in the Software
August 21, 2016
Adler-Milstein J. Falling Between the Cracks in the Software. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/falling-between-cracks-software
The Case
A 61-year-old man with a history of osteoarthritis was scheduled for a total knee replacement. Prio…
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psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
March 28, 2023 - Celebrities have spoken about it, and the culture of social media has normalized talking about mental
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psnet.ahrq.gov/node/33779/psn-pdf
March 01, 2015 - the best approaches to do so, delivery organizations have
tried diverse approaches tailored to the culture
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psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety
January 31, 2020 - November 26, 2019
Perspectives on Safety
Safety Culture
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psnet.ahrq.gov/node/33683/psn-pdf
April 01, 2009 - It is not surprising, therefore, to find a certain tension between the culture of medicine and
the demands
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psnet.ahrq.gov/node/49624/psn-pdf
May 01, 2011 - The challenges presented in this case reflect an outdated culture surrounding disclosure. … In such a situation, should the
accepting physicians share their beliefs directly with the family about
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psnet.ahrq.gov/node/49513/psn-pdf
July 01, 2006 - It would
take a very strong culture of safety to empower them to approach the nurse or a physician to
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psnet.ahrq.gov/perspective/conversation-paul-aylin-mbchb
June 01, 2017 - In one hospital I worked at, the microbiologist had to come in to deal with your blood culture. … So, you were encouraged not to do blood cultures on the weekend.
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psnet.ahrq.gov/web-mm/right-patient-wrong-sample
June 01, 2004 - Examples of ongoing Q tracks programs include monitoring errors in patient wristbands, blood culture … April 1, 2016
Perspective
Update on Safety Culture