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psnet.ahrq.gov/node/46865/psn-pdf
March 07, 2018 - Chasing the 6-sigma: drawing lessons from the cockpit
culture.
March 7, 2018
Hickey EJ, Halvorsen F, Laussen PC, et al. Chasing the 6-sigma: Drawing lessons from the cockpit culture.
J Thorac Cardiovasc Surg. 2017;155(2). doi:10.1016/j.jtcvs.2017.09.097.
https://psnet.ahrq.gov/issue/chasing-6-sigma-drawing-lessons…
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psnet.ahrq.gov/node/36046/psn-pdf
June 21, 2006 - The Future of Emergency Care in the United States Health
System.
June 21, 2006
Institute of Medicine. Washington DC; National Academies Press: 2007.
https://psnet.ahrq.gov/issue/future-emergency-care-united-states-health-system
In September 2003, an Institute of Medicine (IOM) committee began a detailed examinatio…
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psnet.ahrq.gov/node/42673/psn-pdf
October 30, 2013 - Clinical evaluation of the ADE scorecards as a decision
support tool for adverse drug event analysis and
medication safety management.
October 30, 2013
Hackl WO, Ammenwerth E, Marcilly R, et al. Clinical evaluation of the ADE scorecards as a decision
support tool for adverse drug event analysis and medication safe…
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psnet.ahrq.gov/node/851885/psn-pdf
January 01, 2024 - When to err is inhuman: an examination of the influence
of artificial intelligence-driven nursing care on patient
safety.
August 2, 2023
Johnson EA, Dudding KM, Carrington JM. When to err is inhuman: an examination of the influence of
artificial intelligence?driven nursing care on patient safety. Nurs Inq. 2024;31…
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psnet.ahrq.gov/node/838312/psn-pdf
October 12, 2022 - Causes of adverse events in home mechanical
ventilation: a nursing perspective.
October 12, 2022
Lipprandt M, Liedtke W, Langanke M, et al. Causes of adverse events in home mechanical ventilation: a
nursing perspective. BMC Nurs. 2022;21(1):264. doi:10.1186/s12912-022-01038-2.
https://psnet.ahrq.gov/issue/causes-a…
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psnet.ahrq.gov/node/859353/psn-pdf
December 20, 2023 - Global State of Patient Safety 2023.
December 20, 2023
Illingworth J, Shaw A, Fernandez et al. London UK: Imperial College London; 2023.
https://psnet.ahrq.gov/issue/global-state-patient-safety-2023
Patient safety data can support learning health systems and worldwide improvement. This report discusses
a set of in…
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psnet.ahrq.gov/node/47888/psn-pdf
May 11, 2019 - Achieving dialysis safety: the critical role of higher-
functioning teams.
May 11, 2019
Wong LP. Achieving dialysis safety: The critical role of higher-functioning teams. Semin Dial.
2019;32(3):266-273. doi:10.1111/sdi.12778.
https://psnet.ahrq.gov/issue/achieving-dialysis-safety-critical-role-higher-functioning-t…
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psnet.ahrq.gov/node/35417/psn-pdf
February 15, 2010 - Errors in laboratory medicine: practical lessons to
improve patient safety.
February 15, 2010
Howanitz PJ. Errors in laboratory medicine: practical lessons to improve patient safety. Arch Pathol Lab
Med. 2005;129(10):1252-1261.
https://psnet.ahrq.gov/issue/errors-laboratory-medicine-practical-lessons-improve-patie…
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psnet.ahrq.gov/node/47065/psn-pdf
June 20, 2018 - The complexity, diversity, and science of primary care
teams.
June 20, 2018
Fiscella K, McDaniel SH. The complexity, diversity, and science of primary care teams. Amer Psychol.
2018;73(4):451-467. doi:10.1037/amp0000244.
https://psnet.ahrq.gov/issue/complexity-diversity-and-science-primary-care-teams
Teamwork is …
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psnet.ahrq.gov/node/47130/psn-pdf
October 10, 2018 - Are clinical instructors preventing or provoking adverse
events involving students: a contemporary issue.
October 10, 2018
Christensen L. Are clinical instructors preventing or provoking adverse events involving students: A
contemporary issue. Nurse Educ Today. 2018;70:121-123. doi:10.1016/j.nedt.2018.08.024.
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August 02, 2019 - Simulation-based clinical systems testing for healthcare
spaces: from intake through implementation.
August 2, 2019
Colman N, Doughty C, Arnold J, et al. Simulation-based clinical systems testing for healthcare spaces:
from intake through implementation. Adv Simul. 2019;4(1):19. doi:10.1186/s41077-019-0108-7.
http…
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psnet.ahrq.gov/node/45546/psn-pdf
October 05, 2016 - Using standardized OR checklists and creating extended
time-out checklists.
October 5, 2016
Hey LA, Turner TC. Using Standardized OR Checklists and Creating Extended Time-Out Checklists.
AORN J. 2016;104(3):248-53. doi:10.1016/j.aorn.2016.07.007.
https://psnet.ahrq.gov/issue/using-standardized-or-checklists-and-cr…
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psnet.ahrq.gov/node/43585/psn-pdf
July 16, 2015 - At risk care plans: a way to reduce readmissions and
adverse events.
July 16, 2015
Bahle J, Majercik C, Ludwick R, et al. At Risk Care Plans: a way to reduce readmissions and adverse
events. J Nurs Care Qual. 2015;30(3):200-4. doi:10.1097/NCQ.0000000000000106.
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psnet.ahrq.gov/node/34591/psn-pdf
January 04, 2017 - John M. Eisenberg Patient Safety Awards. Safety,
effectiveness, and efficiency: a Web-based virtual
anticoagulation clinic.
January 4, 2017
Kelly JJ, Sweigard KW, Shields K, et al. John M. Eisenberg Patient Safety Awards. Safety, effectiveness,
and efficiency: a Web-based virtual anticoagulation clinic. Jt Comm J …
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psnet.ahrq.gov/node/47753/psn-pdf
April 24, 2019 - Teams of psychologists helping teams: the evolution of
the science of team training.
April 24, 2019
Bisbey TM, Reyes DL, Traylor AM, et al. Teams of psychologists helping teams: The evolution of the
science of team training. Am Psychol. 2019;74(3):278-289. doi:10.1037/amp0000419.
https://psnet.ahrq.gov/issue/teams…
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psnet.ahrq.gov/web-mm/what-was-those-platelets
August 28, 2024 - What Was in Those Platelets?
Citation Text:
Yomtovian R. What Was in Those Platelets? . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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July 01, 2008 - What Was in Those Platelets?
July 1, 2008
Yomtovian R. What Was in Those Platelets? . PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/what-was-those-platelets
The Case
A 47-year-old woman was admitted to the hospital for complex spinal surgery. The surgery went well
without complications, and postoperativel…
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psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
February 20, 2019 - Emerging Safety Issues in Artificial Intelligence
Robert Challen, MA, MBBS | July 1, 2019
View more articles from the same authors.
Citation Text:
Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. Rockville (MD): Agency for Healthcare…
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psnet.ahrq.gov/node/33758/psn-pdf
December 01, 2013 - In Conversation With… Hardeep Singh, MD, MPH
December 1, 2013
In Conversation With… Hardeep Singh, MD, MPH. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
Editor's note: Hardeep Singh, MD, MPH, is Chief of the Health Policy, Quality and Informatics Program at
the Hous…
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June 07, 2023 - Breathe Easy: Safe Tracheostomy Management
Citation Text:
Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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