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psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
September 18, 2024 - SPOTLIGHT CASE
Diagnostic Delay in the Emergency Department
Citation Text:
Marshall K, Singh H. Diagnostic Delay in the Emergency Department. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:…
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psnet.ahrq.gov/node/867653/psn-pdf
February 26, 2025 - In Conversation with Jessica Behrhorst about The
Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. In Conversation with Jessica Behrhorst about The Evolution of Root Cause
Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evoluti…
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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an
Order is Not Enough
April 28, 2021
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
Disclosure of Relev…
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psnet.ahrq.gov/node/857061/psn-pdf
November 27, 2023 - In Conversation with... Joan Stanley about The Role of
Undergraduate Nursing Education in Patient Safety
November 27, 2023
Stanley J. In Conversation with.. Joan Stanley about The Role of Undergraduate Nursing Education in
Patient Safety . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-joa…
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psnet.ahrq.gov/issue/alarm-system-management-evidence-based-guidance-encouraging-direct-measurement
August 11, 2021 - Review
Alarm system management: evidence-based guidance encouraging direct measurement of informativeness to improve alarm response.
Citation Text:
Rayo MF, Moffatt-Bruce SD. Alarm system management: evidence-based guidance encouraging direct measurement of informativeness to improve ala…
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psnet.ahrq.gov/issue/electronic-medical-record-based-interventions-encourage-opioid-prescribing-best-practices
September 01, 2021 - Study
Electronic medical record-based interventions to encourage opioid prescribing best practices in the emergency department.
Citation Text:
Smalley CM, Willner MA, Muir MKR, et al. Electronic medical record-based interventions to encourage opioid prescribing best practices in the emer…
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psnet.ahrq.gov/web-mm/empty-handoff
August 01, 2017 - involved
Structured as communication, then dialogue, then agreement of goals
All team members encouraged … All team members involved in the information transfer and recovery discussions
Speaking up encouraged
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
November 01, 2011 - Anonymous phone lines
Online reporting (likely the most effective)
Patients and families can also be encouraged
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psnet.ahrq.gov/web-mm/stroke-error
February 01, 2016 - Patients may be encouraged, but if they look at the side of the moving fingers appropriately, this can … The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation … The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation
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psnet.ahrq.gov/node/33647/psn-pdf
March 01, 2007 - During rounds in which families are encouraged to participate, physician orders are written on a laptop
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psnet.ahrq.gov/node/40717/psn-pdf
August 24, 2011 - Revealing their medical errors: why three doctors went
public.
August 24, 2011
O'Reilly KB.
https://psnet.ahrq.gov/issue/revealing-their-medical-errors-why-three-doctors-went-public
This news article reports on health care providers who have publicly revealed direct involvement in cases
of medical errors, with a …
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psnet.ahrq.gov/node/848378/psn-pdf
May 04, 2023 - Ensuring competency and safety when onboarding newly
hired professional staff.
May 3, 2023
ISMP Medication Safety Alert! Acute care edition. April 20, 2023;28(8):1-4; May 4, 2023;23(9):1-3.
https://psnet.ahrq.gov/issue/ensuring-competency-and-safety-when-onboarding-newly-hired-professional-
staff
Psychological sa…
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psnet.ahrq.gov/node/73312/psn-pdf
May 26, 2021 - Healthcare professionals experience of psychological
safety, voice, and silence.
May 26, 2021
O'Donovan R, De Brún A, McAuliffe E. Healthcare professionals experience of psychological safety, voice,
and silence. Front Psychol. 2021;12:626689. doi:10.3389/fpsyg.2021.626689.
https://psnet.ahrq.gov/issue/healthcare-p…
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psnet.ahrq.gov/issue/encouraging-employees-speak-prevent-infections-opportunities-leverage-quality-improvement-and
January 23, 2017 - Study
Encouraging employees to speak up to prevent infections: opportunities to leverage quality improvement and care management processes.
Citation Text:
Robbins J, McAlearney AS. Encouraging employees to speak up to prevent infections: Opportunities to leverage quality improvement and …
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psnet.ahrq.gov/node/40009/psn-pdf
November 26, 2014 - Measuring faculty reflection on adverse patient events:
development and initial validation of a case-based
learning system.
November 26, 2014
Wittich CM, Lopez-Jimenez F, Decker LK, et al. Measuring faculty reflection on adverse patient events:
development and initial validation of a case-based learning system. J …
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psnet.ahrq.gov/node/74178/psn-pdf
December 15, 2021 - Strategies to Improve Patient Safety: Final Report to
Congress Required by the Patient Safety and Quality
Improvement Act of 2005.
December 15, 2021
Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-
0009.
https://psnet.ahrq.gov/issue/strategies-improve-patient-safe…
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psnet.ahrq.gov/node/45069/psn-pdf
June 01, 2016 - The effects of power, leadership and psychological safety
on resident event reporting.
June 1, 2016
Appelbaum NP, Dow A, Mazmanian PE, et al. The effects of power, leadership and psychological safety on
resident event reporting. Med Edu. 2016;50(3):343-350. doi:10.1111/medu.12947.
https://psnet.ahrq.gov/issue/effe…
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psnet.ahrq.gov/node/39195/psn-pdf
January 28, 2010 - Lack of patient knowledge regarding hospital
medications.
January 28, 2010
Lack of patient knowledge regarding hospital medications.
https://psnet.ahrq.gov/issue/lack-patient-knowledge-regarding-hospital-medications
The Joint Commission requires that hospitals encourage patients' involvement in their own safety as…
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psnet.ahrq.gov/node/35220/psn-pdf
May 14, 2015 - Patient Safety and Quality Improvement Act of 2005.
May 14, 2015
Pub L No. 109-41.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005
This bill amends the Public Health Service Act to encourage a culture of safety in health care organizations.
The bill, signed into law July 29, 2005…
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psnet.ahrq.gov/node/36378/psn-pdf
October 28, 2010 - Teaching but not learning: how medical residency
programs handle errors.
October 28, 2010
Hoff T, Pohl H, Bartfield J. Teaching but not learning: how medical residency programs handle errors. J
Organ Behav. 2006;27(7). doi:10.1002/job.395.
https://psnet.ahrq.gov/issue/teaching-not-learning-how-medical-residency-pr…