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psnet.ahrq.gov/node/848827/psn-pdf
May 10, 2023 - TQIP Mortality Reporting System Case Reports.
May 10, 2023
ACS TQIP Mortality Reporting System Writing Group. J Trauma Acute Care Surg. 2023.
https://psnet.ahrq.gov/issue/tqip-mortality-reporting-system-case-reports
Anonymous case reporting provides opportunities to examine unexpected patient harm instances to
pin…
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psnet.ahrq.gov/node/45581/psn-pdf
October 19, 2016 - Reducing diagnostic errors.
October 19, 2016
Gittlen S. HealthLeaders Media. October 1, 2016.
https://psnet.ahrq.gov/issue/reducing-diagnostic-errors-0
The recent recognition of diagnostic error as a blind spot in health care has driven the need to enhance
diagnosis. This news article reports how health systems, a…
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psnet.ahrq.gov/node/46221/psn-pdf
July 02, 2017 - Tools and methods for quality improvement and patient
safety in perinatal care.
July 2, 2017
Nathan AT, Kaplan HC. Tools and methods for quality improvement and patient safety in perinatal care.
Semin Perinatol. 2017;41(3):142-150. doi:10.1053/j.semperi.2017.03.002.
https://psnet.ahrq.gov/issue/tools-and-methods-q…
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psnet.ahrq.gov/node/35556/psn-pdf
May 27, 2011 - Improving patient safety using interactive, evidence-
based decision support tools.
May 27, 2011
Quinn MM, Mannion J. Improving patient safety using interactive, evidence-based decision support tools. Jt
Comm J Qual Patient Saf. 2005;31(12):678-683.
https://psnet.ahrq.gov/issue/improving-patient-safety-using-inter…
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psnet.ahrq.gov/node/45364/psn-pdf
September 04, 2016 - A piece of my mind. Changing the narrative.
September 4, 2016
Allen-Dicker J. Changing the Narrative. JAMA. 2016;316(3). doi:10.1001/jama.2016.3029.
https://psnet.ahrq.gov/issue/piece-my-mind-changing-narrative
Storytelling can share knowledge and build community among physicians. However, if clinicians
communicat…
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psnet.ahrq.gov/node/46460/psn-pdf
January 17, 2018 - Association between organisational and workplace
cultures, and patient outcomes: systematic review.
January 17, 2018
Braithwaite J, Herkes J, Ludlow K, et al. Association between organisational and workplace cultures, and
patient outcomes: systematic review. BMJ Open. 2017;7(11). doi:10.1136/bmjopen-2017-017708.
h…
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psnet.ahrq.gov/node/47708/psn-pdf
February 13, 2019 - The role of purple pens in learning to prescribe.
February 13, 2019
Kinston R, McCarville N, Hassell A. The role of purple pens in learning to prescribe. Clin Teach.
2019;16(6):598-603. doi:10.1111/tct.12991.
https://psnet.ahrq.gov/issue/role-purple-pens-learning-prescribe
Interventions utilizing color as visual c…
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psnet.ahrq.gov/node/47414/psn-pdf
May 01, 2019 - Impact of teamwork improvement training on
communication and teamwork climate in ambulatory
reproductive health care.
May 1, 2019
Dodge LE, Nippita S, Hacker MR, et al. Impact of teamwork improvement training on communication and
teamwork climate in ambulatory reproductive health care. J Healthc Risk Manag. 2019;3…
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psnet.ahrq.gov/node/47358/psn-pdf
August 29, 2018 - Double reading in breast cancer screening: cohort
evaluation in the CO-OPS trial.
August 29, 2018
Taylor-Phillips S, Jenkinson D, Stinton C, et al. Double Reading in Breast Cancer Screening: Cohort
Evaluation in the CO-OPS Trial. Radiology. 2018;287(3):749-757. doi:10.1148/radiol.2018171010.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/46253/psn-pdf
August 28, 2017 - Diagnostic stewardship—leveraging the laboratory to
improve antimicrobial use.
August 28, 2017
Morgan DJ, Malani P, Diekema DJ. Diagnostic Stewardship-Leveraging the Laboratory to Improve
Antimicrobial Use. JAMA. 2017;318(7):607-608. doi:10.1001/jama.2017.8531.
https://psnet.ahrq.gov/issue/diagnostic-stewardship-l…
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psnet.ahrq.gov/node/43126/psn-pdf
April 23, 2014 - Safe and appropriate use of insulin and other
antihyperglycemic agents in hospital.
April 23, 2014
Cornish W. Safe and appropriate use of insulin and other antihyperglycemic agents in hospital. Can J
Diabetes. 2014;38(2):94-100. doi:10.1016/j.jcjd.2014.01.002.
https://psnet.ahrq.gov/issue/safe-and-appropriate-use-…
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psnet.ahrq.gov/node/43321/psn-pdf
August 02, 2015 - Costs associated with surgical site infections in Veterans
Affairs hospitals.
August 2, 2015
Schweizer ML, Cullen JJ, Perencevich E, et al. Costs Associated With Surgical Site Infections in Veterans
Affairs Hospitals. JAMA Surg. 2014;149(6):575-81. doi:10.1001/jamasurg.2013.4663.
https://psnet.ahrq.gov/issue/costs…
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psnet.ahrq.gov/node/43249/psn-pdf
June 18, 2014 - Automated and electronically assisted hand hygiene
monitoring systems: a systematic review.
June 18, 2014
Ward MA, Schweizer ML, Polgreen PM, et al. Automated and electronically assisted hand hygiene
monitoring systems: a systematic review. Am J Infect Control. 2014;42(5):472-8.
doi:10.1016/j.ajic.2014.01.002.
ht…
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psnet.ahrq.gov/node/47085/psn-pdf
June 06, 2018 - Medical Device Safety Action Plan: Protecting Patients,
Promoting Public Health.
June 6, 2018
Silver Spring, MD: US Food and Drug Administration; April 2018.
https://psnet.ahrq.gov/issue/medical-device-safety-action-plan-protecting-patients-promoting-public-health
Reliable use of medical devices is an important co…
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psnet.ahrq.gov/node/45077/psn-pdf
May 11, 2016 - Quality of Care and Information Technology.
May 11, 2016
Suresh S, ed. Pediatr Clin North Am. 2016;63:221-388.
https://psnet.ahrq.gov/issue/quality-care-and-information-technology
Utilizing informatics has shown promise for enhancing quality and patient safety, but this has also
introduced unintended consequences.…
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psnet.ahrq.gov/node/853249/psn-pdf
September 06, 2023 - How does robotic-assisted surgery change OR safety
culture?
September 6, 2023
How does robotic-assisted surgery change OR safety culture? AMA J Ethics. 2023;25(8):E615-E623.
doi:10.1001/amajethics.2023.615.
https://psnet.ahrq.gov/issue/how-does-robotic-assisted-surgery-change-or-safety-culture
The safety culture …
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psnet.ahrq.gov/node/46080/psn-pdf
August 28, 2017 - A growth mindset approach to preparing trainees for
medical error.
August 28, 2017
Klein J, Delany C, Fischer MD, et al. A growth mindset approach to preparing trainees for medical error.
BMJ Qual Saf. 2017;26(9):771-774. doi:10.1136/bmjqs-2016-006416.
https://psnet.ahrq.gov/issue/growth-mindset-approach-preparing…
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psnet.ahrq.gov/node/44087/psn-pdf
November 16, 2015 - Teaching a 'good' ward round.
November 16, 2015
Powell N, Bruce CG, Redfern O. Teaching a 'good' ward round. Clin Med (Lond). 2015;15(2):135-138.
doi:10.7861/clinmedicine.15-2-135.
https://psnet.ahrq.gov/issue/teaching-good-ward-round
Ward rounds, while an important educational activity, may not receive the attent…
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psnet.ahrq.gov/node/44889/psn-pdf
April 13, 2017 - An organizational learning framework for patient safety.
April 13, 2017
Edwards MT. An Organizational Learning Framework for Patient Safety. Am J Med Qual. 2016;32(2):148-
155. doi:10.1177/1062860616632295.
https://psnet.ahrq.gov/issue/organizational-learning-framework-patient-safety
Organizations are encouraged t…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/health-it-survey-compendium/care-management-cmp-discussion-guide
January 01, 2023 - Care Management (CMP) Discussion Guide
This is an interview guide designed to be conducted with nurses, physicians, and office staff in an ambulatory setting. The tool includes questions to assess the current state of electronic health records.
Survey Document
Care Management (CMP) Discussion …