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psnet.ahrq.gov/issue/developing-measure-value-health-care
February 10, 2021 - Commentary
Developing a measure of value in health care.
Citation Text:
Ken Lee KH, Matthew Austin J, Pronovost PJ. Developing a measure of value in health care. Value Health. 2015;19(4):323-325. doi:10.1016/j.jval.2014.12.009.
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psnet.ahrq.gov/issue/five-strategies-safer-ehr-modernization-journey
November 11, 2020 - Commentary
Five strategies for a safer EHR modernization journey.
Citation Text:
Sittig DF, Yackel EE, Singh H. Five strategies for a safer EHR modernization journey. J Gen Intern Med. 2023;38(S4):940-942. doi:10.1007/s11606-023-08331-z.
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psnet.ahrq.gov/issue/high-reliability-organization-mindset
April 01, 2020 - Commentary
A high-reliability organization mindset.
Citation Text:
Merchant NB, O’Neal J, Dealino-Perez C, et al. A high-reliability organization mindset. Am J Med Qual. 2022;37(6):504-510. doi:10.1097/jmq.0000000000000086.
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psnet.ahrq.gov/perspective/safety-dentistry
August 01, 2016 - Our contributions to date include summarizing existing information sources (e.g., case reports), establishing
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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - Unpacking principle The failure to elicit all relevant information in establishing a differential diagnosis
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psnet.ahrq.gov/issue/do-no-harm-stories-life-death-and-brain-surgery
January 07, 2019 - Book/Report
Do No Harm: Stories of Life, Death, and Brain Surgery.
Citation Text:
Do No Harm: Stories of Life, Death, and Brain Surgery. Marsh H. New York, NY: Thomas Dunne Books; 2015. ISBN: 9781250065810.
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psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings
June 09, 2021 - Book/Report
Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings.
Citation Text:
Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.
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psnet.ahrq.gov/web-mm/low-totem-pole
October 01, 2003 - SPOTLIGHT CASE
Low on the Totem Pole
Citation Text:
Wachter R. Low on the Totem Pole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/issue/promote-culture-safety-good-catch-reports
November 06, 2015 - Newspaper/Magazine Article
Promote a culture of safety with good catch reports.
Citation Text:
Promote a culture of safety with good catch reports. Wallace SC, Mamrol C, Finley E. PA-PSRS Patient Saf Advis. September 2017;14.
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psnet.ahrq.gov/issue/caring-those-who-care-guide-development-and-implementation-occupational-health-and-safety
June 27, 2018 - Book/Report
Caring for Those Who Care: Guide for the Development and Implementation of Occupational Health and Safety Programmes for Health Workers.
Citation Text:
Caring for Those Who Care: Guide for the Development and Implementation of Occupational Health and Safety Programmes for Hea…
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psnet.ahrq.gov/issue/just-cup-tea-introduction-seips-framework
January 31, 2018 - Audiovisual Presentation
Just a Cup of Tea – an Introduction to the SEIPS Framework.
Citation Text:
Just a Cup of Tea – an Introduction to the SEIPS Framework. Epsom and St Helier University Hospitals. Epsom, UK: National Health Service; March 21, 2023.
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psnet.ahrq.gov/issue/ihi-framework-improving-joy-work
September 06, 2017 - Book/Report
Classic
IHI Framework for Improving Joy in Work.
Citation Text:
IHI Framework for Improving Joy in Work. Perlo J, Balik B, Swensen S, et al. Cambridge, MA: Institute for Healthcare Improvement; 2017.
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psnet.ahrq.gov/issue/judgment-under-uncertainty-heuristics-and-biases
June 02, 2010 - Book/Report
Classic
Judgment under Uncertainty: Heuristics and Biases.
Citation Text:
Judgment under Uncertainty: Heuristics and Biases. Kahneman D, Slovic P, Tversky A, eds. Cambridge, NY: Cambridge University Press; 1982. ISBN: 0521284147.
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psnet.ahrq.gov/issue/cognitive-debiasing-part-1-and-part-2
September 18, 2024 - Commentary
Cognitive debiasing; part 1 and part 2.
Citation Text:
Croskerry P, Singhal G, Mamede S. Cognitive debiasing 1: origins of bias and theory of debiasing. BMJ Qual Saf. 2013;22 Suppl 2:ii58-ii64. doi:10.1136/bmjqs-2012-001712.
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psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
August 21, 2024 - SPOTLIGHT CASE
Don't Dismiss the Dangerous: Obstetric Hemorrhage
Citation Text:
Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - A Sweet Case of Hidden Hydrogen Ions
Citation Text:
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/issue/reaching-summit-discharge-summaries-quality-improvement-project
March 17, 2021 - Study
Reaching the summit of discharge summaries: a quality improvement project.
Citation Text:
Richmond RT, McFadzean IJ, Vallabhaneni P. Reaching the summit of discharge summaries: a quality improvement project. BMJ Open Qual. 2021;10(1):e001142. doi:10.1136/bmjoq-2020-001142.
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psnet.ahrq.gov/issue/shared-understanding-resilient-practices-context-inpatient-suicide-prevention-narrative
December 23, 2020 - Study
Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis.
Citation Text:
Berg SH, Rørtveit K, Walby FA, et al. Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis.…
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psnet.ahrq.gov/issue/value-learning-near-misses-improve-patient-safety-scoping-review
April 27, 2022 - Review
The value of learning from near misses to improve patient safety: a scoping review.
Citation Text:
Woodier N, Burnett C, Moppett I. The value of learning from near misses to improve patient safety: a scoping review. J Patient Saf. 2022;19(1):42-47. doi:10.1097/pts.0000000000001078…
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psnet.ahrq.gov/issue/veterans-health-administration-response-covid-19-crisis-surveillance-action
November 17, 2021 - Commentary
Veterans Health Administration response to the COVID-19 crisis: surveillance to action.
Citation Text:
Charles MA, Yackel EE, Mills PD, et al. Veterans Health Administration response to the COVID-19 crisis: surveillance to action. J Patient Saf. 2022;18(7):686-691. doi:10.1097…