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psnet.ahrq.gov/node/838180/psn-pdf
January 01, 2023 - To err is human, but what happens when surgeons err?
September 28, 2022
Lin JS, Olutoye OO, Samora JB. To err is human, but what happens when surgeons err? J Pediatr Surg.
2023;58(3):496-502. doi:10.1016/j.jpedsurg.2022.06.019.
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June 22, 2009 - Evaluation of nationally mandated drug use reviews to
improve patient safety in nursing homes: a natural
experiment.
June 22, 2009
Briesacher B, Limcangco R, Simoni-Wastila L, et al. Evaluation of nationally mandated drug use reviews to
improve patient safety in nursing homes: a natural experiment. J Am Geriatr So…
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October 01, 2013 - Potential Measures for Clinical-Community Relationships
Clinic/Clinician-Patient Relationships
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Table of Contents
Potential Measures for Clinical-Community Relationships
Acknowledgements
Executive Summary
Introduction
Potential Measure Development Methodology
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June 27, 2014 - Experiences of Agency for Healthcare Research and Quality-funded projects that implemented practices
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July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience
Karen Frush, MD | May 1, 2005
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Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
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November 01, 2005 - Rapid Response Teams: Lessons from the Early
Experience
November 1, 2005
Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
Perspective
Health care organizations throughout the world have ide…
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psnet.ahrq.gov/issue/differential-diagnosis-checklists-reduce-diagnostic-error-differentially-randomised
September 23, 2020 - Study
Differential diagnosis checklists reduce diagnostic error differentially: a randomised experiment.
Citation Text:
Kämmer JE, Schauber SK, Hautz SC, et al. Differential diagnosis checklists reduce diagnostic error differentially: a randomised experiment. Med Educ. 2021;55(10):1172-1…
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psnet.ahrq.gov/issue/impact-covid-19-inpatient-clinical-emergencies-single-center-experience
February 17, 2021 - Study
Impact of COVID-19 on inpatient clinical emergencies: a single-center experience.
Citation Text:
Mitchell OJL, Neefe S, Ginestra JC, et al. Impact of COVID-19 on inpatient clinical emergencies: a single-center experience. Resusc Plus. 2021;6:100135. doi:10.1016/j.resplu.2021.100135…
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hcup-us.ahrq.gov/reports/race/HCR_disparitiesIBformatted.jsp
May 01, 2016 - Reducing Racial and Ethnic Disparities through Health Care Reform: State Experience
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May 01, 2016 - Using Report Cards to Measure Racial and Ethnic Health Disparities: State Experience
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December 09, 2020 - Commentary
Human factors and ergonomics at time of crises: the Italian experience coping with COVID19.
Citation Text:
Albolino S, Dagliana G, Tanzini M, et al. Human factors and ergonomics at time of crises: the Italian experience coping with COVID-19. Int J Qual Health Care. 2021;33(1)…
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psnet.ahrq.gov/issue/eradicating-central-line-associated-bloodstream-infections-statewide-hawaii-experience
January 15, 2014 - Study
Eradicating central line–associated bloodstream infections statewide: the Hawaii experience.
Citation Text:
Lin D, Weeks K, Bauer L, et al. Eradicating Central Line–Associated Bloodstream Infections Statewide. American Journal of Medical Quality. 2011;27(2). doi:10.1177/106286061…
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psnet.ahrq.gov/issue/practical-challenges-introducing-who-surgical-checklist-uk-pilot-experience
September 26, 2012 - Study
Practical challenges of introducing WHO surgical checklist: UK pilot experience.
Citation Text:
Vats A, Vincent CA, Nagpal K, et al. Practical challenges of introducing WHO surgical checklist: UK pilot experience. BMJ. 2010;340(jan13 2). doi:10.1136/bmj.b5433.
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December 20, 2017 - Study
Radiographers' experience of preventing patient safety incidents in the context of radiological examinations.
Citation Text:
Wallin A, Ringdal M, Ahlberg K, et al. Radiographers' experience of preventing patient safety incidents in the context of radiological examinations. Scand J …
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psnet.ahrq.gov/issue/participation-system-thinking-simulation-experience-changes-adverse-event-reporting
July 30, 2014 - Study
Participation in a system-thinking simulation experience changes adverse event reporting.
Citation Text:
Sanko JS, Mckay M. Participation in a system-thinking simulation experience changes adverse event reporting. Simul Healthc. 2020;15(3):167-171. doi:10.1097/sih.0000000000000473.…
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psnet.ahrq.gov/issue/customized-triggers-program-childrens-hospitals-experience-improving-trigger-usability
September 01, 2021 - Study
A customized triggers program: a children's hospital's experience in improving trigger usability.
Citation Text:
Reinhart RM, Safari-Ferra P, Badh R, et al. A customized triggers program: a children's hospital's experience in improving trigger usability. Pediatrics. 2023;151(2):e20…
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psnet.ahrq.gov/issue/embedding-quality-improvement-and-patient-safety-ucla-value-analysis-experience
October 02, 2019 - Commentary
Embedding quality improvement and patient safety - the UCLA value analysis experience.
Citation Text:
Gambone JC, Broder MS. Embedding quality improvement and patient safety: the UCLA value analysis experience. Best Pract Res Clin Obstet Gynaecol. 2007;21(4):581-92.
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February 26, 2025 - In Conversation With…Christine A. Sinsky, MD
February 1, 2016
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In Conversation With…Christine A. Sinsky, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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January 01, 2024 - Current State of Diagnostic Safety: Implications for Research, Practice, and Policy
Appendix B. External Experts for Qualitative Interviews
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Table of Contents
Current State of Diagnostic Safety: Implications for Research, Practice, and Policy
1. Introduction
2. Methods
3…
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January 01, 2024 - Parent, physician, and therapist experience of in-person, hybrid, and all-virtual models of physiatry care for children with special healthcare needs.
Citation
Haynes SC, Davidson L, Tancredi DJ, Burns RD, Garrison SL, Marcin JP. Parent, physician, and therapist experience of in-person, hybrid, and al…