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psnet.ahrq.gov/primer/health-care-associated-infections
December 15, 2024 - Healthcare-associated Infections
Citation Text:
Healthcare - Associated Infections. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/print/pdf/node/866984
January 01, 2020 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Interdisciplinary teamwork
Curated Library
Foundations
Medical teamwork and the evolution of safety science: a critical review.
Neuhaus C, Lutnæs DE, Bergström J. Cogn Technol Work. 2020;22:13-27.
In this narrative review, the authors contr…
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psnet.ahrq.gov/issue/artificial-intelligence-health-care-hope-hype-promise-peril
October 12, 2022 - Book/Report
Artificial Intelligence in Health Care: The Hope, the Hype, the Promise, the Peril.
Citation Text:
Artificial Intelligence in Health Care: The Hope, the Hype, the Promise, the Peril. Matheny M, Israni ST, Ahmed M, et al, eds. Washington, DC: National Academy of Medicine. 2022…
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psnet.ahrq.gov/issue/primer-pdsa-executing-plan-do-study-act-cycles-practice-not-just-name
December 04, 2016 - Review
A primer on PDSA: executing plan–do–study–act cycles in practice, not just in name.
Citation Text:
Leis JA, Shojania KG. A primer on PDSA: executing plan-do-study-act cycles in practice, not just in name. BMJ Qual Saf. 2017;26(7):572-577. doi:10.1136/bmjqs-2016-006245.
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psnet.ahrq.gov/issue/nam-action-collaborative-countering-us-opioid-epidemic
September 29, 2017 - Press Release/Announcement
NAM Action Collaborative on Countering the U.S. Opioid Epidemic.
Citation Text:
NAM Action Collaborative on Countering the U.S. Opioid Epidemic. National Academy of Medicine; Aspen Institute.
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psnet.ahrq.gov/issue/theres-science-team-development-interventions-organizations
January 15, 2020 - Review
There's a science for that: team development interventions in organizations.
Citation Text:
Shuffler ML, DiazGranados D, Salas E. There’s a Science for That. Curr Dir Psychol Sci. 2011;20(6). doi:10.1177/0963721411422054.
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psnet.ahrq.gov/node/36265/psn-pdf
April 21, 2015 - "Health courts" and accountability for patient safety.
April 21, 2015
Mello MM, Studdert DM, Kachalia A, et al. "Health courts" and accountability for patient safety. Milbank Q.
2006;84(3):459-92.
https://psnet.ahrq.gov/issue/health-courts-and-accountability-patient-safety
This article provides an overview of "hea…
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psnet.ahrq.gov/node/43957/psn-pdf
June 21, 2015 - Enhancing the effectiveness of team debriefings in
medical simulation: more best practices.
June 21, 2015
Lyons R, Lazzara EH, Benishek LE, et al. Enhancing the effectiveness of team debriefings in medical
simulation: more best practices. Jt Comm J Qual Patient Saf. 2015;41(3):115-125.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx
Spotlight
Failure to Ensure Patient Safety Leads to Patient Falls in
Nursing Homes
Source and Credits
• This presentation is based on the April 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/we…
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psnet.ahrq.gov/issue/diagnostic-errors-medicine-case-neglect
July 15, 2015 - Study
Diagnostic errors in medicine: a case of neglect.
Citation Text:
Graber ML. Diagnostic errors in medicine: a case of neglect. Jt Comm J Qual Patient Saf. 2005;31(2):106-13.
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psnet.ahrq.gov/issue/patient-safety-and-systematic-reviews-finding-papers-indexed-medline-embase-and-cinahl
August 04, 2021 - Study
Patient safety and systematic reviews: finding papers indexed in MEDLINE, EMBASE and CINAHL.
Citation Text:
Tanon AA, Champagne F, Contandriopoulos A-P, et al. Patient safety and systematic reviews: finding papers indexed in MEDLINE, EMBASE and CINAHL. Qual Saf Health Care. 2010;…
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psnet.ahrq.gov/issue/nurse-managers-leadership-patient-safety-and-quality-care-systematic-review
September 09, 2020 - Review
Nurse managers' leadership, patient safety, and quality of care: a systematic review.
Citation Text:
Lee SE, Hyunjie L, Sang S. Nurse managers' leadership, patient safety, and quality of care: a systematic review. West J Nurs Res. 2023;45(2):176-185. doi:10.1177/01939459221114079.…
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - simulation training for acute care nurses improve patient safety outcomes: a systematic review to inform evidence-based … practice.
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psnet.ahrq.gov/node/33722/psn-pdf
December 01, 2011 - Once the risk factors are identified,
the evidence-based practice piece of this should prompt me as
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psnet.ahrq.gov/issue/quality-initiative-system-wide-reduction-serious-medication-events-through-targeted
April 10, 2024 - Study
A quality initiative: a system-wide reduction in serious medication events through targeted simulation training.
Citation Text:
Hebbar KB, Colman N, Williams L, et al. A Quality Initiative: A System-Wide Reduction in Serious Medication Events Through Targeted Simulation Training. S…
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psnet.ahrq.gov/issue/doing-right-our-patients-when-things-go-wrong-ambulatory-setting
August 14, 2017 - Commentary
Doing right by our patients when things go wrong in the ambulatory setting.
Citation Text:
Schiff G, Griswold P, Ellis BR, et al. Doing right by our patients when things go wrong in the ambulatory setting. Jt Comm J Qual Patient Saf. 2014;40(2):91-96.
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psnet.ahrq.gov/node/72649/psn-pdf
January 20, 2021 - Wrong-site surgery in Pennsylvania during 2015–2019: a
study of variables associated with 368 events from 178
facilities.
January 20, 2021
Yonash RA, Taylor M. Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables
Associated With 368 Events From 178 Facilities. Patient Safety. 2020;2(4):24-39.
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psnet.ahrq.gov/issue/end-beginning-patient-safety-five-years-after-err-human
March 02, 2011 - Commentary
Classic
The end of the beginning: patient safety five years after 'To Err Is Human.'
Citation Text:
Wachter RM. The End Of The Beginning: Patient Safety Five Years After ‘To Err Is Human’. Health Aff. 2004;23(Suppl1). doi:10.1377/hlthaff.w4.534.
C…
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psnet.ahrq.gov/issue/flying-lessons-clinicians-developing-system-2-practice
April 24, 2018 - Commentary
Flying lessons for clinicians: developing system 2 practice.
Citation Text:
Gregoire JN, Alfes CM, Reimer AP, et al. Flying Lessons for Clinicians: Developing System 2 Practice. Air Med J. 2017;36(3):135-137. doi:10.1016/j.amj.2017.02.003.
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D…
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psnet.ahrq.gov/node/33564/psn-pdf
March 15, 2025 - Computerized Provider Order Entry
March 15, 2025
Computerized Provider Order Entry. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/computerized-provider-order-entry
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice…