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psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
July 01, 2006 - Many organizations have elevated the safety officer to an executive-level position, and I think that's … To me, that requires an executive-level person. … authorize action in response to safety concerns or refer the actions to another group, such as the executive … You can develop these types of feedback loops by doing executive walkrounds or by deploying near miss … Innovations
Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary
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psnet.ahrq.gov/issue/mirror-mirror-wall-update-quality-american-health-care-through-patients-lens
August 15, 2007 - Summary
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psnet.ahrq.gov/issue/physicians-and-electronic-health-records-statewide-survey
December 31, 2014 - Study
Physicians and electronic health records: a statewide survey.
Citation Text:
Simon SR, Kaushal R, Cleary PD, et al. Physicians and electronic health records: a statewide survey. Arch Intern Med. 2007;167(5):507-12.
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psnet.ahrq.gov/issue/interventions-reducing-medication-errors-children-hospital
May 19, 2018 - PubMed citation
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psnet.ahrq.gov/issue/safety-issues-related-electronic-medical-record-emr-synthesis-literature-last-decade-2000
January 20, 2016 - February 23, 2022
Evidence summary and recommendations for improved communication during
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psnet.ahrq.gov/issue/debriefing-medical-teams-12-evidence-based-best-practices-and-tips
February 15, 2011 - Patient Safety Innovations
Rescue Improvement Conference Innovation Summary
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psnet.ahrq.gov/issue/electronic-health-record-programs-participation-has-increased-action-needed-achieve-goals
September 07, 2016 - Free full text (PDF)
Summary (PDF)
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psnet.ahrq.gov/issue/va-health-care-va-uses-medical-injury-tort-claims-data-assess-veterans-care-should-take
February 10, 2010 - Free full text (PDF)
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psnet.ahrq.gov/issue/few-adverse-events-hospitals-were-reported-state-adverse-event-reporting-systems
January 20, 2010 - Summary
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psnet.ahrq.gov/issue/enhancing-safety-reporting-adult-ambulatory-oncology-clinician-champion-practice-innovation
January 05, 2017 - Innovations
Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary
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psnet.ahrq.gov/issue/placing-diagnosis-errors-policy-agenda
October 31, 2014 - Summary (PDF)
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psnet.ahrq.gov/issue/va-health-care-selected-credentialing-requirements-seven-medical-facilities-met-aspect
July 05, 2006 - Available at
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psnet.ahrq.gov/issue/human-cognition-and-dynamics-failure-rescue-lewis-blackman-case
April 24, 2018 - Patient Safety Innovations
Rescue Improvement Conference Innovation Summary
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psnet.ahrq.gov/issue/administering-and-monitoring-high-alert-medications-acute-care
February 01, 2017 - Commentary
Administering and monitoring high-alert medications in acute care.
Citation Text:
Cajanding JMR. Administering and monitoring high-alert medications in acute care. Nurs Stand. 2017;31(47):42-52. doi:10.7748/ns.2017.e10849.
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psnet.ahrq.gov/issue/health-it-patient-safety-action-and-surveillance-plan
December 18, 2013 - Free full text (PDF)
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psnet.ahrq.gov/issue/incorporating-metacognition-morbidity-and-mortality-rounds-next-frontier-quality-improvement
September 21, 2016 - Patient Safety Innovations
Rescue Improvement Conference Innovation Summary
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psnet.ahrq.gov/issue/partnering-patients-and-families-design-patient-and-family-centered-health-care-system
November 29, 2017 - Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary
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psnet.ahrq.gov/issue/leadership-framework-culture-change-health-care
January 02, 2017 - Innovations
Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary
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psnet.ahrq.gov/issue/association-resident-fatigue-and-distress-perceived-medical-errors
February 02, 2011 - Study
Association of resident fatigue and distress with perceived medical errors.
Citation Text:
West CP, Tan AD, Habermann TM, et al. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302(12):1294-300. doi:10.1001/jama.2009.1389.
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psnet.ahrq.gov/issue/introduction-computerized-physician-order-entry-and-change-management-tertiary-pediatric
January 22, 2016 - October 28, 2015
Summary and frequency of barriers to adoption of CPOE in the US.