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psnet.ahrq.gov/issue/organizational-culture-important-context-addressing-and-improving-hospital-community-patient
December 30, 2014 - Study
Organizational culture: an important context for addressing and improving hospital to community patient discharge.
Citation Text:
Hesselink G, Vernooij-Dassen M, Pijnenborg L, et al. Organizational culture: an important context for addressing and improving hospital to community pa…
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psnet.ahrq.gov/issue/measuring-patient-safety-medicare-patient-safety-monitoring-system-past-present-and-future
December 18, 2014 - Review
Measuring patient safety: the Medicare Patient Safety Monitoring System (past, present, and future).
Citation Text:
Classen D, Munier W, Verzier N, et al. Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future). J Patient Saf. 2021;17(3)…
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psnet.ahrq.gov/issue/veterans-affairs-shift-change-physician-physician-handoff-project
April 30, 2014 - Study
The Veterans Affairs shift change physician-to-physician handoff project.
Citation Text:
Anderson J, Shroff D, Curtis A, et al. The Veterans Affairs shift change physician-to-physician handoff project. Jt Comm J Qual Patient Saf. 2010;36(2):62-71.
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psnet.ahrq.gov/issue/qualitative-survey-factors-shaping-role-safety-professional
August 12, 2020 - Study
A qualitative survey of factors shaping the role of a safety professional.
Citation Text:
Van Wassenhove W, Foussard C, Dekker SWA, et al. A qualitative survey of factors shaping the role of a safety professional. Safety Sci. 2022;154:105835. doi:10.1016/j.ssci.2022.105835.
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psnet.ahrq.gov/issue/measuring-teamwork-health-care-settings-review-survey-instruments
December 14, 2016 - Review
Measuring teamwork in health care settings: a review of survey instruments.
Citation Text:
Valentine MA, Nembhard IM, Edmondson A. Measuring teamwork in health care settings: a review of survey instruments. Med Care. 2015;53(4):e16-e30. doi:10.1097/MLR.0b013e31827feef6.
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psnet.ahrq.gov/issue/high-reliability-organization-mindset
April 01, 2020 - Commentary
A high-reliability organization mindset.
Citation Text:
Merchant NB, O’Neal J, Dealino-Perez C, et al. A high-reliability organization mindset. Am J Med Qual. 2022;37(6):504-510. doi:10.1097/jmq.0000000000000086.
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psnet.ahrq.gov/issue/facing-ambiguous-threats
December 24, 2008 - Commentary
Facing ambiguous threats.
Citation Text:
Roberto MA, Bohmer RMJ, Edmondson A. Facing ambiguous threats. Harv Bus Rev. 2006;84(11):106-13, 157.
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Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/issue/development-swarm-model-high-reliability-rapid-problem-solving-and-institutional-learning
November 16, 2022 - Commentary
Development of "SWARM" as a model for high reliability, rapid problem solving, and institutional learning.
Citation Text:
Williams EA, Nikolai DA, Ladwig L, et al. Development of "SWARM" as a Model for High Reliability, Rapid Problem Solving, and Institutional Learning. Jt Com…
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psnet.ahrq.gov/issue/conversations-diagnostic-uncertainty-and-its-management-among-pediatric-acute-care-physicians
March 17, 2021 - Study
Conversations on diagnostic uncertainty and its management among pediatric acute care physicians.
Citation Text:
Patel SJ, Ipsaro A, Brady PW. Conversations on diagnostic uncertainty and its management among pediatric acute care physicians. Hosp Pediatr. 2022;12(3):317-324. doi:10.…
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psnet.ahrq.gov/issue/negative-behaviours-health-care-prevalence-and-strategies
May 01, 2024 - Study
Negative behaviours in health care: prevalence and strategies.
Citation Text:
Layne DM, Nemeth LS, Mueller M, et al. Negative behaviours in health care: Prevalence and strategies. J Nurs Manag. 2019;27(1):154-160. doi:10.1111/jonm.12660.
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psnet.ahrq.gov/issue/impact-pharmacist-provided-medication-therapy-management-healthcare-quality-and-utilization
November 16, 2022 - Study
Impact of pharmacist-provided medication therapy management on healthcare quality and utilization in recently discharged elderly patients.
Citation Text:
Haag JD, Davis AZ, Hoel RW, et al. Impact of Pharmacist-Provided Medication Therapy Management on Healthcare Quality and Utiliza…
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psnet.ahrq.gov/issue/building-learning-organization
June 16, 2011 - Study
Classic
Building a learning organization.
Citation Text:
Garvin DA. Building a learning organization. Harv Bus Rev. 1993;71(4):78-91.
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Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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psnet.ahrq.gov/issue/utilizing-pharmacy-students-transitions-care-services
October 19, 2022 - Commentary
Utilizing pharmacy students in transitions-of-care services.
Citation Text:
L'Hommedieu T, DeCoske M, Lababidi RE, et al. Utilizing pharmacy students in transitions-of-care services. Am J Health Syst Pharm. 2015;72(15):1266-8. doi:10.2146/ajhp140561.
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psnet.ahrq.gov/issue/zero-harm-health-care
August 12, 2020 - Commentary
Zero harm in health care.
Citation Text:
Gandhi TK, Feeley D, Schummers D. Zero Harm in Health Care. NEJM Catal Innov Care Deliv. 2020;1(2). doi:10.1056/cat.19.1137.
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psnet.ahrq.gov/issue/are-personal-health-records-phrs-facilitating-patient-safety-scoping-review
February 09, 2022 - Review
Are personal health records (PHRs) facilitating patient safety? A scoping review.
Citation Text:
Joseph AL, Monkman H, Kushniruk AW, et al. Are personal health records (PHRs) facilitating patient safety? A scoping review. Stud Health Technol Inform. 2022;2022:535-539. doi:10.3233/…
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psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
March 01, 2018 - understanding that resolution may not be possible ( 4 ), so that safe patient care is supported and enhanced
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psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
February 26, 2025 - When we put work settings through this we found that the resilience is enhanced, the work–life balance
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psnet.ahrq.gov/node/846170/psn-pdf
March 15, 2023 - Duplicate Therapies in Retail Pharmacy
March 15, 2023
Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
The Cases
Case 1: A middle-aged man with a past medical history of heart failure with reduced ejection f…
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psnet.ahrq.gov/node/49651/psn-pdf
May 01, 2012 - The Perils of Cross Coverage
May 1, 2012
Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/perils-cross-coverage
Case Objectives
Explain the recently instituted ACGME duty hour regulations for 2011 as they pertain to handoffs and
care transitions.
Describe ed…
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psnet.ahrq.gov/node/49506/psn-pdf
March 01, 2006 - The Wet Read
March 1, 2006
Arenson RL. The Wet Read. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/wet-read
Case Objectives
Appreciate the limitations of radiology resident emergency coverage.
Understand the rate of discrepancy between radiology resident preliminary reads and attending
radiologists' fina…