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psnet.ahrq.gov/node/46346/psn-pdf
October 29, 2017 - root-cause-analysis-icu-adverse-events-veterans-health-administration
Root cause analysis is widely utilized in health care to examine
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psnet.ahrq.gov/node/43532/psn-pdf
June 23, 2017 - This study presents the development and validation
of a survey tool, the SVEST, to examine clinicians
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psnet.ahrq.gov/node/46207/psn-pdf
July 19, 2017 - This report from a national initiative to
examine burnout provides initial insights from its work and
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psnet.ahrq.gov/node/41561/psn-pdf
August 01, 2012 - few-adverse-events-hospitals-were-reported-state-adverse-event-reporting-
systems
This report built on earlier research to examine
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psnet.ahrq.gov/node/34797/psn-pdf
October 06, 2015 - Discussion includes characteristics of the upgraded
system, a process-tracing technique to examine the
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psnet.ahrq.gov/node/42784/psn-pdf
January 15, 2014 - multi-disciplinary-approach-medication-safety-and-implication-nursing-
education-and-practice
This study used direct observation and interviews to examine
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psnet.ahrq.gov/node/42916/psn-pdf
February 05, 2014 - are-autopsy-findings-still-relevant-management-critically-ill-patients-modern-
era
This study used a blinded review of medical records matched with autopsy findings to examine
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psnet.ahrq.gov/node/47010/psn-pdf
March 13, 2019 - This study used data
from the Human Diagnosis Project (Human Dx, an online case-solving platform) to examine
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psnet.ahrq.gov/node/47357/psn-pdf
October 03, 2018 - Investigators conducted a systematic review to examine the effects of fatigue on both providers and
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psnet.ahrq.gov/curated-library/organizational-learning
April 04, 2025 - High reliability organizations consistently examine what goes wrong and remain aware that failure can … High reliability organizations consistently examine and learn from failures. … High reliability organizations consistently examine and learn from failures. … High reliability organizations consistently examine what goes wrong and remain aware that failure can … scale and nature of serious failures in the United Kingdom’s National Health Service (NHS) system, examine
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psnet.ahrq.gov/issue/legacy-black-physician-reckons-racism-medicine
March 20, 2024 - This memoir draws from a Black woman's experience as both a clinician and a patient to examine failures
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psnet.ahrq.gov/issue/ahrq-funded-patient-safety-project-highlights-improving-patient-safety-enhancing-care
August 07, 2024 - This publication summarizes 47 projects that examine the impact of care coordination to enhance patient
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psnet.ahrq.gov/issue/cognitive-autopsy-root-cause-analysis-medical-decision-making
December 18, 2019 - This publication uses clinical cases to examine cognitive elements that contribute to problematic decision
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psnet.ahrq.gov/issue/nhs-staff-cried-safety-interviews-says-watchdog
August 30, 2023 - This news story discusses an ongoing investigation in the British National Health Service to examine
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psnet.ahrq.gov/node/43927/psn-pdf
December 04, 2015 - This randomized controlled trial of different resident shift lengths (12, 16, and 24 hours) sought to examine
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psnet.ahrq.gov/node/45510/psn-pdf
October 19, 2016 - such as story maps and cause-and-effect
diagrams that support the use of this structured approach to examine
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psnet.ahrq.gov/node/44592/psn-pdf
December 02, 2015 - communication style of the attending was scripted to either be more hierarchical or
more inclusive in order to examine
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psnet.ahrq.gov/node/34796/psn-pdf
November 18, 2015 - The authors examine four case studies to explore the financial and clinical implications of
quality
-
psnet.ahrq.gov/node/47204/psn-pdf
July 18, 2018 - Researchers utilized data from
the Centers for Disease Control and Prevention to examine opioid-related
-
psnet.ahrq.gov/node/34829/psn-pdf
April 06, 2011 - use-medical-emergency-team-responses-reduce-hospital-cardiopulmonary-
arrests
This study is the first in the United States to examine