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psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-paramedics-provide-home
October 30, 2024 - facility efforts should focus on
Ensuring necessary staffing to schedule and complete home visits,
Establishing
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psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-and-performance
September 23, 2024 - respiratory therapists, physical therapists, social workers, case management staff, and pharmacy staff)
Establishing
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psnet.ahrq.gov/primer/nursing-and-patient-safety
September 15, 2024 - The process of establishing nurse staffing on a unit-by-unit and shift-by-shift basis is discussed in
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psnet.ahrq.gov/issue/science-teamwork
May 01, 2013 - Special or Theme Issue
The Science of Teamwork.
Citation Text:
The Science of Teamwork. McDaniel SH, Salas E, eds. Am Psychol. 2018;73:305-600.
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psnet.ahrq.gov/issue/do-you-know-what-doses-are-being-programmed-or-make-it-expectation-use-smart-infusion-pumps
February 26, 2025 - Newspaper/Magazine Article
Do you know what doses are being programmed in the OR? Make it an expectation to use smart infusion pumps with DERS.
Citation Text:
Do you know what doses are being programmed in the OR? Make it an expectation to use smart infusion pumps with DERS. ISMP Medicat…
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psnet.ahrq.gov/issue/canadian-patient-safety-dictionary
September 13, 2017 - Glossary
Canadian Patient Safety Dictionary.
Citation Text:
Canadian Patient Safety Dictionary. Royal College of Physicians and Surgeons of Canada
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psnet.ahrq.gov/issue/press-play-safety-conversations
August 24, 2022 - Multi-use Website
Press Play on Safety Conversations.
Citation Text:
Press Play on Safety Conversations. Healthcare Excellence Canada. 2022.
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psnet.ahrq.gov/issue/giving-back-pen-disclosure-apology-and-early-compensation-discussions-after-harm-healthcare
April 26, 2012 - Commentary
Giving back the pen: disclosure, apology and early compensation discussions after harm in the healthcare setting.
Citation Text:
Giving back the pen: disclosure, apology and early compensation discussions after harm in the healthcare setting. Pelletier E, Robson. Healthc Q…
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psnet.ahrq.gov/issue/nursing-home-antimicrobial-stewardship-guide
November 23, 2016 - Toolkit
Nursing Home Antimicrobial Stewardship Guide.
Citation Text:
Nursing Home Antimicrobial Stewardship Guide. Rockville, MD: Agency for Healthcare Research and Quality; October 2016.
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psnet.ahrq.gov/issue/center-patient-safety
May 01, 2016 - Multi-use Website
Center for Patient Safety.
Citation Text:
Center for Patient Safety. Missouri State Medical Association; Missouri Hospital Association; Primaris
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psnet.ahrq.gov/issue/patient-safety-17
April 30, 2024 - Newsletter/Journal
Patient Safety.
Citation Text:
Patient Safety. Harrisburg, PA: Patient Safety Authority. ISSN 2641-4716.
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psnet.ahrq.gov/issue/nhs-redress-act-2006
June 12, 2013 - Legislation/Case Law
NHS Redress Act 2006.
Citation Text:
NHS Redress Act 2006. United Kingdom Parliament, 2006 Chapter 44.
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psnet.ahrq.gov/issue/medstar-health-institute-quality-and-safety
July 13, 2022 - Multi-use Website
MedStar Health Institute for Quality and Safety.
Citation Text:
MedStar Health Institute for Quality and Safety. MedStar Health. 10980 Grantchester Way, Columbia, MD 21044.
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psnet.ahrq.gov/issue/center-excellence-improving-diagnosis
April 30, 2024 - Multi-use Website
Center of Excellence for Improving Diagnosis.
Citation Text:
Center of Excellence for Improving Diagnosis. Patient Safety Authority.
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psnet.ahrq.gov/issue/center-diagnostic-excellence
July 09, 2019 - Multi-use Website
Center for Diagnostic Excellence.
Citation Text:
Center for Diagnostic Excellence. Armstrong Institute for Patient Safety and Quality
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psnet.ahrq.gov/issue/healthcare-simulation-nursing-practice
July 08, 2020 - Special or Theme Issue
Healthcare Simulation in Nursing Practice.
Citation Text:
Watts PI. Healthcare Simulation in Nursing Practice. Nurs Clin North Am. 2024;59(3):345-510.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…
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psnet.ahrq.gov/issue/learn-not-blame
November 14, 2011 - Multi-use Website
Learn Not Blame.
Citation Text:
Learn Not Blame. Doctors' Association UK.
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July 31, 2019
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psnet.ahrq.gov/issue/special-focus-issue-patient-safety
November 06, 2015 - Special or Theme Issue
Special Focus Issue: Patient Safety.
Citation Text:
Special Focus Issue: Patient Safety. Wagner VD, ed. AORN J. 2014;100:351-456.
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psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd
October 01, 2007 - Establishing a just culture within an organization requires action on three fronts: building awareness
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psnet.ahrq.gov/node/49495/psn-pdf
December 01, 2005 - Low on the Totem Pole
December 1, 2005
Wachter R. Low on the Totem Pole. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/low-totem-pole
Case Objectives
Understand the concept of authority gradient
List steps that can be taken to increase communication across an authority gradient
Consider the current cultu…