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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41643/psn-pdf
    September 05, 2012 - issue/randomized-field-study-leadership-walkrounds-based-intervention Leadership WalkRounds have been described
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47257/psn-pdf
    September 26, 2018 - An Annual Perspective described the challenges in measuring and responding to serious patient harm.
  3. psnet.ahrq.gov/primer/failure-rescue
    September 15, 2024 - For example, Gaba described most anesthetic accidents as evolving from small errors and system failures … Causes and Prevention of Failure-to-Rescue Previous research has described three critical stages that … A 2022 systematic review described this paradigm as the 3Rs (recognize, relay and react) underpinning … such as the need for external model validation to ensure generalizability. 3 Recent research has also described
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48112/psn-pdf
    July 10, 2019 - A WebM&M commentary described a chemotherapy infusion error that caused renal failure.
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48060/psn-pdf
    June 19, 2019 - Perspective discussed problematic prescribing practices that likely contribute to adverse events and described
  6. psnet.ahrq.gov/issue/courage-speak-out-study-describing-nurses-attitudes-report-unsafe-practices-patient-care
    April 24, 2018 - A recent WebM&M commentary described how leaders can encourage and reward speaking up.
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43632/psn-pdf
    December 19, 2014 - should-i-report-qualitative-study-barriers-incident-reporting-among-nurses- working-nursing In this qualitative study, nursing staff in long-term care facilities described
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34665/psn-pdf
    December 24, 2008 - Two contrasting theoretical models of learning are introduced, with the traditional model described
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45129/psn-pdf
    August 03, 2016 - A PSNet perspective described how fatigue can affect physician performance.
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46664/psn-pdf
    December 22, 2018 - Perspective reviewed problematic prescribing practices that likely contribute to adverse events and described
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34784/psn-pdf
    June 24, 2015 - Team dimensions, behaviors, and activities are described in detail.
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46833/psn-pdf
    December 03, 2018 - A past WebM&M commentary described the harms associated with inappropriate antibiotic use.
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42683/psn-pdf
    December 02, 2014 - restrictions negatively affect resident education and continuity of care, and almost half of those surveyed described
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35703/psn-pdf
    July 13, 2010 - injury-and-liability-associated-monitored-anesthesia-care-closed-claims- analysis Using closed malpractice claims from a previously described
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45690/psn-pdf
    June 28, 2017 - Challenges associated with checklist implementation are well described.
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45596/psn-pdf
    January 09, 2018 - This study described the myriad challenges faced by the National Health Service (NHS) in its quest to
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45085/psn-pdf
    May 04, 2016 - A WebM&M commentary described best practices for opioid prescribing.
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45445/psn-pdf
    September 27, 2016 - using-kotters-change-model-implementing-bedside-handoff-quality- improvement-project Change management has been described
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44887/psn-pdf
    March 16, 2016 - Participants believed teamwork and safety culture had improved, but they described challenges to implementing
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44257/psn-pdf
    November 06, 2015 - systems-approach-evaluating-ionizing-radiation-six-focus-areas-improve- quality-efficiency-and Radiation therapy has been described

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