-
psnet.ahrq.gov/node/47070/psn-pdf
June 25, 2018 - Time out—charting a path for improving performance
measurement.
June 25, 2018
MacLean CH, Kerr EA, Qaseem A. Time Out - Charting a Path for Improving Performance Measurement. N
Engl J Med. 2018;378(19):1757-1761. doi:10.1056/NEJMp1802595.
https://psnet.ahrq.gov/issue/time-out-charting-path-improving-performance-me…
-
psnet.ahrq.gov/node/72502/psn-pdf
November 25, 2020 - Patient safety in primary care: conceptual meanings to
the health care team and patients.
November 25, 2020
Lai AY. Patient safety in primary care: conceptual meanings to the health care team and patients. J Am
Board Fam Med. 2020;33(5):754-764. doi:10.3122/jabfm.2020.05.200042.
https://psnet.ahrq.gov/issue/patien…
-
psnet.ahrq.gov/node/41976/psn-pdf
March 11, 2013 - Moving beyond readmission penalties: creating an ideal
process to improve transitional care.
March 11, 2013
Burke RE, Kripalani S, Vasilevskis EE, et al. Moving beyond readmission penalties: creating an ideal
process to improve transitional care. J Hosp Med. 2013;8(2):102-9. doi:10.1002/jhm.1990.
https://psnet.ahr…
-
psnet.ahrq.gov/node/47841/psn-pdf
April 24, 2019 - Criminalisation of unintentional error in healthcare in the
UK: a perspective from New Zealand.
April 24, 2019
Ameratunga R, Klonin H, Vaughan J, et al. Criminalisation of unintentional error in healthcare in the UK: a
perspective from New Zealand. BMJ. 2019;364:l706. doi:10.1136/bmj.l706.
https://psnet.ahrq.gov/i…
-
psnet.ahrq.gov/node/33790/psn-pdf
August 01, 2015 - were identified many years ago, in classic human factors literature and through
application in other domains
-
psnet.ahrq.gov/node/836876/psn-pdf
May 16, 2022 - Modifications to language and domains of the existing SOPs were necessary because the prehospital
setting
-
psnet.ahrq.gov/node/43274/psn-pdf
September 27, 2016 - Distractions in the operating room.
September 27, 2016
Feil M. PA-PSRS Patient Saf Advis. June 2014;11:45-52.
https://psnet.ahrq.gov/issue/distractions-operating-room
Operating rooms are complex environments with particular risks regarding interruptions and distractions.
This article draws from data reported to th…
-
psnet.ahrq.gov/node/40219/psn-pdf
December 29, 2014 - Cardiac surgery errors: results from the UK National
Reporting and Learning System.
December 29, 2014
Martinez EA, Shore AD, Colantuoni E, et al. Cardiac surgery errors: results from the UK National Reporting
and Learning System. Int J Qual Health Care. 2011;23(2):151-8. doi:10.1093/intqhc/mzq084.
https://psnet.ah…
-
psnet.ahrq.gov/node/49544/psn-pdf
September 01, 2007 - as conforming to the
performance measure, hospitals are required to provide instructions in all six domains … According to the Joint Commission and Medicare, providing HF education in six key domains at
discharge
-
psnet.ahrq.gov/node/43355/psn-pdf
July 23, 2014 - Nearing zero...reducing grade C medication errors.
July 23, 2014
Cockerham J, Figueroa-Altmann A, Foxen C, et al. Nearing zero..reducing grade C medication errors. Nurs
Manage. 2014;45(7):26-31. doi:10.1097/01.NUMA.0000451033.38845.d3.
https://psnet.ahrq.gov/issue/nearing-zeroreducing-grade-c-medication-errors
Thi…
-
psnet.ahrq.gov/node/60265/psn-pdf
January 01, 2019 - Quality Improvement and Patient Safety Competencies
Across the Learning Continuum.
January 1, 2019
AAMC New and Emerging Areas in Medicine Series. Washington, DC: Association of American Medical
Colleges; 2019. ISBN: 9781577541882.
https://psnet.ahrq.gov/issue/quality-improvement-and-patient-safety-competencies-ac…
-
psnet.ahrq.gov/node/47126/psn-pdf
May 16, 2018 - Unintended adverse consequences of a clinical decision
support system: two cases.
May 16, 2018
Stone EG. Unintended adverse consequences of a clinical decision support system: two cases. J Am Med
Inform Assoc. 2018;25(5):564-567. doi:10.1093/jamia/ocx096.
https://psnet.ahrq.gov/issue/unintended-adverse-consequence…
-
psnet.ahrq.gov/node/44763/psn-pdf
November 18, 2016 - A 'paperless' wall-mounted surgical safety checklist with
migrated leadership can improve compliance and team
engagement.
November 18, 2016
Ong APC, Devcich DA, Hannam J, et al. A 'paperless' wall-mounted surgical safety checklist with migrated
leadership can improve compliance and team engagement. BMJ Qual Saf. 2…
-
psnet.ahrq.gov/node/61057/psn-pdf
October 28, 2020 - Improving Diagnostic Quality and Safety/Reducing
Diagnostic Error: Measurement Considerations. Final
Report
October 28, 2020
Washington DC; National Quality Forum: October 6, 2020.
https://psnet.ahrq.gov/issue/improving-diagnostic-quality-and-safetyreducing-diagnostic-error-
measurement-considerations
With input…
-
psnet.ahrq.gov/perspective/conversation-richard-platt-md-msc
October 01, 2016 - In other domains where prediction is applied—like which movie or product you may enjoy—the consequences
-
psnet.ahrq.gov/node/34845/psn-pdf
June 30, 2011 - The JCAHO patient safety event taxonomy: a
standardized terminology and classification schema for
near misses and adverse events.
June 30, 2011
Chang A, Schyve PM, Croteau RJ, et al. The JCAHO patient safety event taxonomy: a standardized
terminology and classification schema for near misses and adverse events. In…
-
psnet.ahrq.gov/node/47370/psn-pdf
October 10, 2018 - Development of a conceptual map of negative
consequences for patients of overuse of medical tests
and treatments.
October 10, 2018
Korenstein D, Chimonas S, Barrow B, et al. Development of a Conceptual Map of Negative Consequences
for Patients of Overuse of Medical Tests and Treatments. JAMA Intern Med. 2018;178(1…
-
psnet.ahrq.gov/node/49820/psn-pdf
February 01, 2018 - template that
(i) embeds transition planning into the SNF's routines of care and (ii) delineates the domains
-
psnet.ahrq.gov/node/50611/psn-pdf
October 30, 2019 - Finally, it must be mentioned that this error occurred in the context of two high-risk clinical domains … situational awareness of the various things that can go wrong and potential for new errors
in these domains
-
psnet.ahrq.gov/node/37542/psn-pdf
February 23, 2018 - Handbook of Human Factors and Ergonomics in Health
Care and Patient Safety. 2nd ed.
February 23, 2018
Carayon P, ed. Boca Raton, FL: CRC Press; 2017. ISBN: 9781439830338
https://psnet.ahrq.gov/issue/handbook-human-factors-and-ergonomics-health-care-and-patient-safety-2nd-
ed
Human factors principles are widely ap…