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psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
November 04, 2015 - Practices should decide on a standardized system for notifying patients of both normal and abnormal results
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psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
August 01, 2018 - MW : In an optimal world of value-based care, you would see at least some organizations decide that simulation … For example, the FDA [Food and Drug Administration] may decide that new, complex, and high-risk procedures … The Joint Commission may also decide to step in.
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psnet.ahrq.gov/perspective/conversation-matthew-weinger-md
August 01, 2018 - MW : In an optimal world of value-based care, you would see at least some organizations decide that simulation … For example, the FDA [Food and Drug Administration] may decide that new, complex, and high-risk procedures … The Joint Commission may also decide to step in.
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psnet.ahrq.gov/issue/assessing-patient-safety-pediatric-telemedicine-setting-multi-methods-study
May 01, 2024 - Study
Emerging Classic
Assessing patient safety in a pediatric telemedicine setting: a multi-methods study.
Citation Text:
Haimi M, Brammli-Greenberg S, Baron-Epel O, et al. Assessing patient safety in a pediatric telemedicine setting: a multi-methods study. BMC…
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psnet.ahrq.gov/issue/patient-safety-and-just-culture-primer-health-care-executives
July 24, 2013 - Book/Report
Classic
Patient Safety and the "Just Culture": A Primer for Health Care Executives.
Citation Text:
Marx DA. Patient Safety And The "Just Culture": A Primer For Health Care Executives. New York, NY: Trustees of Columbia University; 2001.
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psnet.ahrq.gov/node/49819/psn-pdf
February 01, 2018 - Signout Fallout
February 1, 2018
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/signout-fallout
Case Objectives
Understand the role of communication failures in medical errors and preventable adverse events.
Review the evidence in support of handoff improvement pr…
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psnet.ahrq.gov/web-mm/communication-error-closed-icu
July 01, 2016 - Communication Error in a Closed ICU
Citation Text:
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google Scholar BibTeX EndNote X3 XML En…
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - SPOTLIGHT CASE
Signout Fallout
Citation Text:
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote…
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psnet.ahrq.gov/issue/charges-and-lengths-stay-attributable-adverse-patient-care-events-using-pediatric-specific
January 04, 2021 - Study
Charges and lengths of stay attributable to adverse patient-care events using pediatric-specific quality indicators: a multicenter study of freestanding children's hospitals.
Citation Text:
Kronman MP, Hall M, Slonim A, et al. Charges and lengths of stay attributable to adverse p…
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psnet.ahrq.gov/issue/effect-program-shorten-decision-delivery-interval-emergent-cesarean-section-maternal-and
April 12, 2019 - Study
The effect of a program to shorten the decision-to-delivery interval for emergent cesarean section on maternal and neonatal outcome.
Citation Text:
Weiner E, Bar J, Fainstein N, et al. The effect of a program to shorten the decision-to-delivery interval for emergent cesarean sectio…
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psnet.ahrq.gov/issue/whats-past-prologue-organizational-learning-serious-patient-injury
October 26, 2011 - Study
What’s past is prologue: organizational learning from a serious patient injury.
Citation Text:
Tamuz M, Franchois KE, Thomas EJ. What’s past is prologue: Organizational learning from a serious patient injury. Saf Sci. 2010;49(1). doi:10.1016/j.ssci.2010.06.005.
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…
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psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
August 01, 2006 - Getting Into Patient Safety: A Personal Story
Jeffrey B. Cooper, PhD | August 1, 2006
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Cooper JB. Getting Into Patient Safety: A Personal Story. PSNet [internet]. Rockville (MD): A…
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psnet.ahrq.gov/node/49591/psn-pdf
October 01, 2009 - The Executive Medical Board then deliberates to decide whether the physician's actions warrant a
reduction
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psnet.ahrq.gov/issue/what-counts-voiceable-concern-decisions-about-speaking-out-hospitals-qualitative-study
June 16, 2021 - Study
What counts as a voiceable concern in decisions about speaking out in hospitals: a qualitative study.
Citation Text:
Dixon-Woods M, Aveling EL, Campbell A, et al. What counts as a voiceable concern in decisions about speaking out in hospitals: a qualitative study. J Health Serv Res…
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psnet.ahrq.gov/issue/comparison-focused-family-cancer-history-questionnaire-family-history-documentation
June 23, 2021 - Study
Comparison of a focused family cancer history questionnaire to family history documentation in the electronic medical record.
Citation Text:
Clift K, Macklin-Mantia S, Barnhorst M, et al. Comparison of a focused family cancer history questionnaire to family history documentation in…
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psnet.ahrq.gov/node/49858/psn-pdf
April 01, 2019 - What Happened on Telemetry?
April 1, 2019
Sandau KE, Funk M. What Happened on Telemetry? PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/what-happened-telemetry
Case Objectives
Describe current hospital practices for continuous telemetry monitoring.
Appreciate key recommendations from the Update to Practice…
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psnet.ahrq.gov/node/843234/psn-pdf
January 01, 2013 - adjustment in patients with CKD.However, drug-disease
alerts are often passive (meaning the clinician must decide … worked with their drug-disease knowledge software vendor, physicians and pharmacists to
iteratively decide
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005
View more articles from the same authors.
Citation Text:
Conway JB, Weingart SN. Organizational Change…
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psnet.ahrq.gov/node/33639/psn-pdf
September 01, 2006 - you the vulnerabilities, and it's for
us, through our prioritization system and further analysis, to decide
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psnet.ahrq.gov/node/49658/psn-pdf
July 01, 2012 - downstream to analyze and apply the results or prompts (e.g.,
stop to consider alternative diagnoses or decide