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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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-…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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.…
  16. Psn-Pdf (pdf file)

    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 …
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. 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 …