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psnet.ahrq.gov/node/46087/psn-pdf
September 24, 2017 - Who is responsible for the safe introduction of new
surgical technology? An important legal precedent from
the da Vinci Surgical System Trials.
September 24, 2017
Pradarelli J, Thornton JP, Dimick JB. Who Is Responsible for the Safe Introduction of New Surgical
Technology?: An Important Legal Precedent From the da…
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psnet.ahrq.gov/node/844765/psn-pdf
September 18, 2019 - Untangling infusion confusion: a comparative evaluation
of interventions in a simulated intensive care setting.
September 18, 2019
Pinkney SJ, Fan M, Koczmara C, et al. Untangling Infusion Confusion: A Comparative Evaluation of
Interventions in a Simulated Intensive Care Setting. Crit Care Med. 2019;47(7):e597-e601…
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psnet.ahrq.gov/node/45230/psn-pdf
July 20, 2016 - Outcomes are worse in US patients undergoing surgery
on weekends compared with weekdays.
July 20, 2016
Glance LG, Osler T, Li Y, et al. Outcomes are Worse in US Patients Undergoing Surgery on Weekends
Compared With Weekdays. Med Care. 2016;54(6):608-15. doi:10.1097/MLR.0000000000000532.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/39745/psn-pdf
September 09, 2010 - Duty hours in emergency medicine: balancing patient
safety, resident wellness, and the resident training
experience: a consensus response to the 2008 Institute of
Medicine resident duty hours recommendations.
September 9, 2010
Wagner MJ, Wolf S, Promes S, et al. Duty hours in emergency medicine: balancing patient …
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psnet.ahrq.gov/node/48019/psn-pdf
June 26, 2019 - Please reconcile, not wait a while.
June 26, 2019
Trivedi A, Sharma S, Ajitsaria R, et al. Please reconcile, not wait a while. Arch Dis Child Educ Pract Ed.
2019;105(2):122-126. doi:10.1136/archdischild-2018-316356.
https://psnet.ahrq.gov/issue/please-reconcile-not-wait-while
Medication reconciliation to ensure ac…
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psnet.ahrq.gov/node/46873/psn-pdf
June 27, 2018 - Diagnostic errors and the bedside clinical examination.
June 27, 2018
Clark BW, Derakhshan A, Desai S. Diagnostic Errors and the Bedside Clinical Examination. Med Clin North
Am. 2018;102(3):453-464. doi:10.1016/j.mcna.2017.12.007.
https://psnet.ahrq.gov/issue/diagnostic-errors-and-bedside-clinical-examination
Diag…
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psnet.ahrq.gov/node/50418/psn-pdf
January 01, 2020 - Experiential learning through local implementation of a
national chief resident in quality and patient safety
curriculum.
September 1, 2019
Ronan MV, Menon A, Swamy L, et al. Experiential Learning Through Local Implementation of a National
Chief Resident in Quality and Patient Safety Curriculum. American Journal o…
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psnet.ahrq.gov/node/46984/psn-pdf
April 04, 2018 - Educator toolkits on second victim syndrome,
mindfulness and meditation, and positive psychology: the
2017 Resident Wellness Consensus Summit.
April 4, 2018
Chung AS, Smart J, Zdradzinski M, et al. Educator Toolkits on Second Victim Syndrome, Mindfulness and
Meditation, and Positive Psychology: The 2017 Resident W…
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psnet.ahrq.gov/node/50651/psn-pdf
November 13, 2019 - How effective is teamwork really? The relationship
between teamwork and performance in healthcare teams:
a systematic review and meta-analysis.
November 13, 2019
Schmutz JB, Meier LL, Manser T. How effective is teamwork really? The relationship between teamwork
and performance in healthcare teams: a systematic rev…
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psnet.ahrq.gov/node/45432/psn-pdf
September 14, 2016 - Clinical decision support: a 25 year retrospective and a 25
year vision.
September 14, 2016
Middleton B, Sittig DF, Wright A. Clinical Decision Support: a 25 Year Retrospective and a 25 Year Vision.
Yearb Med Inform. 2016;Suppl 1:S103-16. doi:10.15265/IYS-2016-s034.
https://psnet.ahrq.gov/issue/clinical-decision-s…
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psnet.ahrq.gov/node/43978/psn-pdf
September 01, 2016 - Optimizing smart pump technology by increasing critical
safety alerts and reducing clinically insignificant alerts.
September 1, 2016
Mansfield J, Jarrett S. Optimizing smart pump technology by increasing critical safety alerts and reducing
clinically insignificant alerts. Hosp Pharm. 2015;50(2):113-7. doi:10.1310/…
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psnet.ahrq.gov/node/45013/psn-pdf
April 13, 2016 - Good Practice Guides on Medication Errors: Part 1 and
Part 2.
April 13, 2016
Goedecke T, Ord K, Newbould V, et al. Medication Errors: New Eu Good Practice Guide On Risk
Minimisation And Error Prevention. Springer Science and Business Media LLC; 2016. doi:10.1007/s40264-
016-0410-4.
https://psnet.ahrq.gov/issue/go…
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psnet.ahrq.gov/node/43277/psn-pdf
June 18, 2014 - The Food and Drug Administration's initiative for safe
design and effective use of home medical equipment.
June 18, 2014
Weick-Brady M, Singh S. The Food and Drug Administration's initiative for safe design and effective use of
home medical equipment. Home Healthc Nurse. 2014;32(6):343-8. doi:10.1097/NHH.0000000000…
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psnet.ahrq.gov/node/43799/psn-pdf
January 07, 2015 - Omission of high-alert medications: a hidden danger.
January 7, 2015
Grissinger M, Alghamdi D. PA-PSRS Patient Saf Advis. December 2014;11:149-155.
https://psnet.ahrq.gov/issue/omission-high-alert-medications-hidden-danger
Analyzing incidents reported over a 4-month period, this article reveals that 21% of 2700 med…
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/cre.pdf
September 26, 2019 - hospital’s multi-faceted intervention included antibiotic
stewardship measures, contact isolation, and enhanced … Toth et al.,
201719
• Enhanced contact isolation
• Active surveillance
The model’s intervention … Active
surveillance and enhanced contact isolation were found to be successful in one model of LTACHs … high
Organism: CP-KP
Toth et al.,
201719
Mathematical
model that
measured the
effects of
enhanced … The enhanced isolation
model accounted for patients
contributing 75% less to
transmission rate compared
-
www.ahrq.gov/sites/default/files/2024-01/vanschaik-report.pdf
January 01, 2024 - in the data: 1) changing interactions between facilitators, 2)
shift in debriefing content, and 3) enhanced … Theme 3: Enhanced interprofessional learning
Prior to implementation of the guidelines, interprofessional … team dynamics and created an environment in which interprofessional learning
between team members was enhanced … A history of simulation-enhanced interprofessional
education.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-implementation-factraining-guide.pdf
June 02, 2025 - o Process efficiencies and enhanced team communication
save the staff time.
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psnet.ahrq.gov/print/pdf/node/865308
January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Organizational Learning
Curated Library
Foundations
Organizational learning: health care leaders need to design structures and processes that enhance
collective learning.
Bohmer RM, Edmondson AC. Health Forum J. 2001;44:32-35.
This comment…
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs023960-rudin-final-report-2018.pdf
January 01, 2018 - Using mHealth and Patient-Reported Outcomes to Deliver Evidence-Based Asthma Care - Final Report
Using mHealth and Patient-Reported Outcomes to Deliver Evidence-Based Asthma Care
Final Report
Principal Investigator and Team Members: Robert S. Rudin, PI; Maria O. Edelen, Co-I; David W.
Bates, Co…
-
psnet.ahrq.gov/curated-library/maternal-safety
January 31, 2024 - Breadcrumb
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team
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