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psnet.ahrq.gov/node/47030/psn-pdf
June 06, 2018 - Creating a safer operating room: groups, team dynamics
and crew resource management principles.
June 6, 2018
Wakeman D, Langham MR. Creating a safer operating room: Groups, team dynamics and crew resource
management principles. Semin Pediatr Surg. 2018;27(2):107-113. doi:10.1053/j.sempedsurg.2018.02.008.
https://p…
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psnet.ahrq.gov/node/60650/psn-pdf
July 01, 2020 - COVID-19 can last for several months. The disease’s
“long-haulers” have endured relentless waves of
debilitating symptoms—and disbelief from doctors and
friends.
July 1, 2020
Young E. COVID-19 can last for several months. The disease’s “long-haulers” have endured relentless
waves of debilitating symptoms—and disb…
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www.ahrq.gov/talkingquality/distribute/promote/multiple/index.html
September 01, 2019 - Using Multiple Strategies To Promote a Health Care Quality Report
Effective promotion of a comparative quality report requires a multi-faceted approach. Even if you have focused carefully on a particular group, you are still trying to communicate with a large and probably diverse audience. That means that the…
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psnet.ahrq.gov/node/45859/psn-pdf
August 03, 2017 - Root cause analysis and actions for the prevention of
medical errors: quality improvement and resident
education.
August 3, 2017
Charles R, Hood B, DeRosier JM, et al. Root Cause Analysis and Actions for the Prevention of Medical
Errors: Quality Improvement and Resident Education. Orthopedics. 2017;40(4):e628-e635…
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psnet.ahrq.gov/node/61101/psn-pdf
November 04, 2020 - Investigation into Management of Venous
Thromboembolism Risk in Patients Following
Thrombolysis for an Acute Stroke.
November 4, 2020
Farnborough, UK; Healthcare Safety Investigation Branch. October 2020
https://psnet.ahrq.gov/issue/investigation-management-venous-thromboembolism-risk-patients-following-
thrombol…
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psnet.ahrq.gov/node/60613/psn-pdf
June 24, 2020 - A sociotechnical framework for safety-related electronic
health record research reporting: the SAFER reporting
framework.
June 24, 2020
Singh H, Sittig DF. A sociotechnical framework for safety-related electronic health record research
reporting: the SAFER reporting framework. Ann Intern Med. 2020;172(11_Supp):S92…
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psnet.ahrq.gov/node/47596/psn-pdf
March 27, 2019 - Mortality and morbidity rounds (MMR) in pathology:
relative contribution of cognitive bias vs. systems failures
to diagnostic error.
March 27, 2019
Eichbaum Q, Adkins B, Craig-Owens L, et al. Mortality and morbidity rounds (MMR) in pathology: relative
contribution of cognitive bias vs. systems failures to diagnost…
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psnet.ahrq.gov/node/853241/psn-pdf
September 06, 2023 - Hiding in plain sight: inconvenient facts for patient safety
in non-24/7 theatre on-site staffed obstetric units.
September 6, 2023
McGurgan P. Hiding in plain sight: Inconvenient facts for patient safety in non?24/7 theatre on?site staffed
obstetric units. Aust N Z J Obstet Gynaecol. 2023;63(4):606-611. doi:10.111…
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psnet.ahrq.gov/node/43909/psn-pdf
March 11, 2015 - Summary and frequency of barriers to adoption of CPOE
in the US.
March 11, 2015
Kruse CS, Goetz K. Summary and frequency of barriers to adoption of CPOE in the U.S. J Med Syst.
2015;39(2):15. doi:10.1007/s10916-015-0198-2.
https://psnet.ahrq.gov/issue/summary-and-frequency-barriers-adoption-cpoe-us
Although compu…
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psnet.ahrq.gov/node/44568/psn-pdf
October 21, 2015 - Developing and deploying a patient safety program in a
large health care delivery system: you can't fix what you
don't know about.
October 21, 2015
Bagian JP, Lee C, Gosbee J, et al. Developing and deploying a patient safety program in a large health
care delivery system: you can't fix what you don't know about. J…
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psnet.ahrq.gov/node/866937/psn-pdf
October 09, 2024 - Improving nursing home safety through adoption of a
practical resilient health care approach.
October 9, 2024
Hartmann CW, Clark V, Nash P, et al. Improving nursing home safety through adoption of a practical
resilient health care approach. J Am Med Dir Assoc. 2024;25(9):105014. doi:10.1016/j.jamda.2024.03.124.
ht…
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psnet.ahrq.gov/node/72504/psn-pdf
November 25, 2020 - Impact of SARS-CoV-2 on hospital acquired infection
rates in the United States: predictions and early results.
November 25, 2020
McMullen KM, Smith BA, Rebmann T. Impact of SARS-CoV-2 on hospital acquired infection rates in the
United States: predictions and early results. Am J Infect Control. 2020;48(11):1409-1411…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/1-2023hcbs-survey-webcast-shaller.pdf
June 06, 2024 - Participating in the 2023 CAHPS® Home and Community-Based Services Survey Database: What You Need to Know - Opening
Participating in the 2023 CAHPS® Home and
Community-Based Services (HCBS CAHPS) Survey
Database: What You Need to Know
A Webcast Presented by the AHRQ CAHPS User Network
June 6, 2024
3:30pm
Webc…
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psnet.ahrq.gov/node/35511/psn-pdf
May 31, 2011 - An objective methodology for task analysis and workload
assessment in anesthesia providers.
May 31, 2011
Weinger M B, Herndon O W, Zornow M H, et al. An Objective Methodology for Task Analysis and Workload
Assessment in Anesthesia Providers. Anesthesiology. 2006;80(1):77-92. doi:10.1097/00000542-
199401000-00015.
…
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psnet.ahrq.gov/node/43812/psn-pdf
January 14, 2015 - Healthcare Inspection: Evaluation of the Veterans Health
Administration's National Consult Delay Review and
Associated Fact Sheet.
January 14, 2015
Daigh JD Jr. Washington, DC: VA Office of the Inspector General; December 15, 2014. Report No. 14-
04705-62.
https://psnet.ahrq.gov/issue/healthcare-inspection-evalua…
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psnet.ahrq.gov/node/46830/psn-pdf
May 30, 2018 - A call to bridge across silos during care transitions.
May 30, 2018
Sheikh F, Gathecha E, Bellantoni M, et al. A Call to Bridge Across Silos during Care Transitions. Jt Comm
J Qual Patient Saf. 2018;44(5):270-278. doi:10.1016/j.jcjq.2017.10.006.
https://psnet.ahrq.gov/issue/call-bridge-across-silos-during-care-tran…
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psnet.ahrq.gov/node/866447/psn-pdf
August 07, 2024 - Older adults are often misdiagnosed. Specialized ERs and
trained clinicians can help.
August 7, 2024
Milne-Tyte A. Older adults are often misdiagnosed. Specialized ERs and trained clinicians can help. Health
Shots. National Public Radio. July 30, 2024;
https://psnet.ahrq.gov/issue/older-adults-are-often-misdiagnos…
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psnet.ahrq.gov/node/856634/psn-pdf
January 01, 2024 - Perspectives on perioperative team-based morbidity and
mortality conferences: a mixed-methods study.
November 29, 2023
Samost-Williams A, Rosen R, Cummins E, et al. Perspectives on Perioperative Team-Based Morbidity and
Mortality Conferences: A Mixed Methods Study. Jt Comm J Qual Patient Saf. 2024;50(2):139-148.
d…
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psnet.ahrq.gov/node/74037/psn-pdf
January 01, 2022 - Looking back on the history of patient safety: an
opportunity to reflect and ponder future challenges.
November 3, 2021
Schiff G, Shojania KG. Looking back on the history of patient safety: an opportunity to reflect and ponder
future challenges. BMJ Qual Saf. 2022;31(2):148-152. doi:10.1136/bmjqs-2021-014163.
http…
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psnet.ahrq.gov/node/851456/psn-pdf
July 19, 2023 - Nurses and nursing students as second victims: a
scoping review.
July 19, 2023
Sahay A, McKenna L. Nurses and nursing students as second victims: a scoping review. Nurs Outlook.
2023;71(4):101992. doi:10.1016/j.outlook.2023.101992.
https://psnet.ahrq.gov/issue/nurses-and-nursing-students-second-victims-scoping-rev…