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psnet.ahrq.gov/node/847041/psn-pdf
April 05, 2023 - Frontline nurses' clinical judgment in recognizing,
understanding, and responding to patient deterioration: a
qualitative study.
April 5, 2023
Dresser S, Teel C, Peltzer J. Frontline nurses' clinical judgment in recognizing, understanding, and
responding to patient deterioration: a qualitative study. Int J Nurs St…
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psnet.ahrq.gov/node/34736/psn-pdf
October 24, 2017 - Medical Problem Solving: An Analysis of Clinical
Reasoning.
October 24, 2017
Elstein AS, ed. Cambridge, MA: Harvard University Press; 1978. ISBN: 9780674561250.
https://psnet.ahrq.gov/issue/medical-problem-solving-analysis-clinical-reasoning
Clinical reasoning lies at the heart of formulating diagnoses and selecti…
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psnet.ahrq.gov/node/43004/psn-pdf
September 24, 2016 - Shift change handovers and subsequent interruptions:
potential impacts on quality of care.
September 24, 2016
Estryn-Behar MR, Milanini-Magny G, Chaumon E, et al. Shift change handovers and subsequent
interruptions: potential impacts on quality of care. J Patient Saf. 2014;10(1):29-44.
doi:10.1097/PTS.000000000000…
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psnet.ahrq.gov/node/43822/psn-pdf
July 01, 2016 - Multicentre study to develop a medication safety package
for decreasing inpatient harm from omission of time-
critical medications.
July 1, 2016
Graudins LV, Ingram C, Smith BT, et al. Multicentre study to develop a medication safety package for
decreasing inpatient harm from omission of time-critical medications.…
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psnet.ahrq.gov/node/60927/psn-pdf
September 16, 2020 - Amid COVID-19, discipline against bad doctors plummets;
more medical errors may slip through cracks.
September 16, 2020
O'Donnell J. USA Today. September 8, 2020
https://psnet.ahrq.gov/issue/amid-covid-19-discipline-against-bad-doctors-plummets-more-medical-errors-
may-slip-through
Management and clinical functio…
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psnet.ahrq.gov/node/852797/psn-pdf
August 23, 2023 - Anaesthesia and patient safety in the socio-technical
operating theatre: a narrative review spanning a century.
August 23, 2023
Webster CS, Mahajan R, Weller JM. Anaesthesia and patient safety in the socio-technical operating
theatre: a narrative review spanning a century. Br J Anaesth. 2023;131(2):397-406.
doi:10…
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psnet.ahrq.gov/node/74748/psn-pdf
February 09, 2022 - The abrupt expansion of ambulatory telemedicine:
implications for patient safety.
February 9, 2022
Khoong EC, Sharma AE, Gupta K, et al. The abrupt expansion of ambulatory telemedicine: implications for
patient safety. J Gen Intern Med. 2022;37(5):1270-1274. doi:10.1007/s11606-021-07329-9.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/43147/psn-pdf
July 19, 2017 - ACOG Committee Opinion #590: preparing for clinical
emergencies in obstetrics and gynecology.
July 19, 2017
Improvement AC of O and GC on PS and Q. Committee opinion no. 590: preparing for clinical emergencies
in obstetrics and gynecology. Obstet Gynecol. 2014;123(3):722-5.
doi:10.1097/01.AOG.0000444442.04111.c6.
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www.ahrq.gov/talkingquality/distribute/promote/multiple/index.html
September 01, 2019 - Using Multiple Strategies To Promote a Health Care Quality Report
Effective promotion of a comparative quality report requires a multi-faceted approach. Even if you have focused carefully on a particular group, you are still trying to communicate with a large and probably diverse audience. That means that the…
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psnet.ahrq.gov/node/73895/psn-pdf
September 29, 2021 - Open Notes shines light on errors in patient medical
records — will the new rule lead to a flood of correction
requests?
September 29, 2021
Clark C. MedPage Today. September 14, 2021.
https://psnet.ahrq.gov/issue/open-notes-shines-light-errors-patient-medical-records-will-new-rule-lead-
flood-correctio…
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psnet.ahrq.gov/node/865871/psn-pdf
May 15, 2024 - Delivery at an inadequate level of maternal care is
associated with severe maternal morbidity.
May 15, 2024
Osei-Poku GK, Prentice JC, Easter SR, et al. Delivery at an inadequate level of maternal care is associated
with severe maternal morbidity. Am J Obstet Gynecol. 2024;231(5):e1-546.e520.
doi:10.1016/j.ajog.20…
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psnet.ahrq.gov/node/843084/psn-pdf
January 25, 2023 - A scoping review of non-professional medication
practices and medication safety outcomes during public
health emergencies.
January 25, 2023
Kelly D, Koay A, Mineva G, et al. A scoping review of non-professional medication practices and
medication safety outcomes during public health emergencies. Public Health. 202…
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psnet.ahrq.gov/node/43812/psn-pdf
January 14, 2015 - Healthcare Inspection: Evaluation of the Veterans Health
Administration's National Consult Delay Review and
Associated Fact Sheet.
January 14, 2015
Daigh JD Jr. Washington, DC: VA Office of the Inspector General; December 15, 2014. Report No. 14-
04705-62.
https://psnet.ahrq.gov/issue/healthcare-inspection-evalua…
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psnet.ahrq.gov/node/45505/psn-pdf
July 01, 2017 - A model for the departmental quality management
infrastructure within an academic health system.
July 1, 2017
Mathews SC, Demski R, Hooper JE, et al. A Model for the Departmental Quality Management
Infrastructure Within an Academic Health System. Acad Med. 2017;92(5):608-613.
doi:10.1097/ACM.0000000000001380.
htt…
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psnet.ahrq.gov/node/73107/psn-pdf
April 07, 2021 - Crisis checklists in emergency medicine: another step
forward for cognitive aids.
April 7, 2021
Chen Y-YK, Arriaga AF. Crisis checklists in emergency medicine: another step forward for cognitive aids.
BMJ Qual Saf. 2021;30(9):689-693. doi:10.1136/bmjqs-2021-013203.
https://psnet.ahrq.gov/issue/crisis-checklists-em…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit6-14.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 6.14. Major Factors that Facilitated Lean Success
Previous Page Next Page
Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare
C…
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psnet.ahrq.gov/node/852287/psn-pdf
August 09, 2023 - Electronic health record usability contributions to patient
safety and clinician burnout: a path forward.
August 9, 2023
Schwappach DLB, Ratwani RM. Electronic health record usability contributions to patient safety and
clinician burnout: a path forward. J Patient Saf. 2023;19(5):38-39. doi:10.1097/pts.000000000000…
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psnet.ahrq.gov/node/73142/psn-pdf
April 14, 2021 - Enhancing safety in high-risk operations: a multilevel
analysis of the role of mindful organising in translating
safety climate into individual safety behaviours.
April 14, 2021
Renecle M, Curcuruto M, Gracia Lerín FJ, et al. Enhancing safety in high-risk operations: a multilevel
analysis of the role of mindful or…
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psnet.ahrq.gov/node/47989/psn-pdf
August 14, 2019 - Ambulatory safety nets to reduce missed and delayed
diagnoses of cancer.
August 14, 2019
Emani S, Sequist TD, Lacson R, et al. Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses
of Cancer. Jt Comm J Qual Patient Saf. 2019;45(8):552-557. doi:10.1016/j.jcjq.2019.05.010.
https://psnet.ahrq.gov/issue/ambula…
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psnet.ahrq.gov/node/50375/psn-pdf
September 25, 2019 - Medical error in the care of the unrepresented: disclosure
and apology for a vulnerable patient population.
September 25, 2019
Byju AS, Mayo K. Medical error in the care of the unrepresented: disclosure and apology for a vulnerable
patient population. J Med Ethics. 2019;45(12):821-823. doi:10.1136/medethics-2019-10…