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psnet.ahrq.gov/issue/understanding-why-quality-initiatives-succeed-or-fail-sociotechnical-systems-perspective
March 10, 2021 - Commentary
Understanding why quality initiatives succeed or fail: a sociotechnical systems perspective.
Citation Text:
Wiegmann DA. Understanding Why Quality Initiatives Succeed or Fail: A Sociotechnical Systems Perspective. Ann Surg. 2016;263(1):9-11. doi:10.1097/SLA.0000000000001333.
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psnet.ahrq.gov/issue/community-living-centers-va-needs-strengthen-its-approach-addressing-resident-complaints
October 12, 2022 - Book/Report
Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints.
Citation Text:
Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints. Washington, DC: United States Government Accountability Office; N…
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psnet.ahrq.gov/issue/organisation-memory-report-expert-group-learning-adverse-events-nhs-chaired-chief-medical
June 12, 2013 - Book/Report
Classic
An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS Chaired by the Chief Medical Officer.
Citation Text:
An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events …
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psnet.ahrq.gov/issue/patient-perceptions-missed-nursing-care
September 27, 2017 - Study
Patient perceptions of missed nursing care.
Citation Text:
Kalisch BJ, McLaughlin M, Dabney BW. Patient perceptions of missed nursing care. Jt Comm J Qual Patient Saf. 2012;38(4):161-7.
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psnet.ahrq.gov/issue/taking-bullying-out-health-care-patient-safety-imperative
June 19, 2024 - Commentary
Taking bullying out of health care: a patient safety imperative.
Citation Text:
Ross J. Taking Bullying Out of Health Care: A Patient Safety Imperative. J Perianesth Nurs. 2017;32(6):653-655. doi:10.1016/j.jopan.2017.08.006.
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psnet.ahrq.gov/issue/ten-years-after-keeping-patients-safe-have-nurses-work-environments-been-transformed
April 04, 2018 - Book/Report
Ten Years After Keeping Patients Safe: Have Nurses' Work Environments Been Transformed?
Citation Text:
Ten Years After Keeping Patients Safe: Have Nurses' Work Environments Been Transformed? Princeton, NJ: Robert Wood Johnson Foundation. Washington, DC: George Washington Un…
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psnet.ahrq.gov/issue/recognizing-excellence-diagnosis-recommended-practices-hospitals
June 21, 2023 - Book/Report
Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals.
Citation Text:
Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals. Washington, DC: Leapfrog Group; July 2024.
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psnet.ahrq.gov/issue/importance-cognitive-errors-diagnosis-and-strategies-minimize-them
September 18, 2024 - Study
Classic
The importance of cognitive errors in diagnosis and strategies to minimize them.
Citation Text:
Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780.
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psnet.ahrq.gov/issue/john-m-eisenberg-patient-safety-awards-system-innovation-concord-hospital
October 19, 2022 - Commentary
John M. Eisenberg Patient Safety Awards. System innovation: Concord Hospital.
Citation Text:
Uhlig PN, Brown J, Nason AK, et al. John M. Eisenberg Patient Safety Awards. System innovation: Concord Hospital. Jt Comm J Qual Improv. 2002;28(12):666-672.
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psnet.ahrq.gov/issue/american-college-radiology-white-paper-mr-safety-2004-update-and-revisions
September 28, 2022 - Clinical Guideline
American College of Radiology White Paper on MR Safety: 2004 Update and Revisions.
Citation Text:
doi:10.2214/ajr.182.5.182111.
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psnet.ahrq.gov/issue/organizational-learning-hospitals-realist-review
June 19, 2019 - Review
Organizational learning in hospitals: a realist review.
Citation Text:
Lyman B, Jacobs JD, Hammond EL, et al. Organizational learning in hospitals: A realist review. J Adv Nurs. 2019;75(11):2352-2377. doi:10.1111/jan.14091.
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psnet.ahrq.gov/issue/concept-analysis-systems-thinking
August 20, 2018 - Review
A concept analysis of systems thinking.
Citation Text:
Stalter AM, Phillips JM, Ruggiero JS, et al. A Concept Analysis of Systems Thinking. Nurs Forum. 2017;52(4):323-330. doi:10.1111/nuf.12196.
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psnet.ahrq.gov/issue/communication-and-teamwork-patient-care-how-much-can-we-learn-aviation
August 12, 2019 - Review
Communication and teamwork in patient care: how much can we learn from aviation?
Citation Text:
Lyndon A. Communication and teamwork in patient care: how much can we learn from aviation? J Obstet Gynecol Neonatal Nurs. 2006;35(4):538-46.
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psnet.ahrq.gov/issue/strategies-improve-patient-safety-final-report-congress-required-patient-safety-and-quality
June 21, 2016 - Book/Report
Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005.
Citation Text:
Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005.…
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psnet.ahrq.gov/issue/seeing-systems-health-care-organizations
January 25, 2023 - Commentary
Seeing systems in health care organizations.
Citation Text:
Friedman LH, King JB, Bella D. Seeing systems in health care organizations. Physician Exec. 2007;33(4):20-9.
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psnet.ahrq.gov/issue/thinking-fast-and-slow-medicine
June 21, 2017 - Commentary
Thinking fast and slow in medicine.
Citation Text:
Michel JB. Thinking fast and slow in medicine. Baylor U Med Center Proceed. 2019;33(1):123-125. doi:10.1080/08998280.2019.1674043.
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psnet.ahrq.gov/issue/improving-patient-understanding-prescription-drug-label-instructions
April 16, 2010 - Study
Improving patient understanding of prescription drug label instructions.
Citation Text:
Davis TC, Federman AD, Bass PF, et al. Improving patient understanding of prescription drug label instructions. J Gen Intern Med. 2009;24(1):57-62. doi:10.1007/s11606-008-0833-4.
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psnet.ahrq.gov/issue/multifaceted-approach-improve-patient-safety-prevent-medical-errors-and-resolve-professional
June 12, 2008 - Commentary
A multifaceted approach to improve patient safety, prevent medical errors and resolve the professional liability crisis.
Citation Text:
Weinstein L. A multifacited approach to improve patient safety, prevent medical errors and resolve the professional liability crisis. Am J …
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psnet.ahrq.gov/issue/diagnostic-centers-excellence-partnerships-improve-diagnostic-safety-and-quality-r18
March 08, 2023 - Grant Announcement
Diagnostic Centers of Excellence: Partnerships to Improve Diagnostic Safety and Quality (R18).
Citation Text:
Diagnostic Centers of Excellence: Partnerships to Improve Diagnostic Safety and Quality (R18). Rockville, MD: Agency for Healthcare Research and Quality; April…
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psnet.ahrq.gov/issue/designing-and-delivering-whole-person-transitional-care-hospital-guide-reducing-medicaid
March 27, 2019 - Toolkit
Designing and Delivering Whole-Person Transitional Care: Hospital Guide to Reducing Medicaid Readmissions.
Citation Text:
Designing and Delivering Whole-Person Transitional Care: Hospital Guide to Reducing Medicaid Readmissions. Boutwell A, Bourgoin A , Maxwell J, et al. Rockvill…