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psnet.ahrq.gov/node/45966/psn-pdf
April 05, 2017 - surgical-fires-clear-and-present-danger
https://psnet.ahrq.gov/issue/sages-fuse-program-bridging-patient-safety-gap
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psnet.ahrq.gov/node/46429/psn-pdf
October 04, 2017 - The authors recommend employing both workflow and technology
solutions to address this safety gap.
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psnet.ahrq.gov/node/45014/psn-pdf
July 18, 2016 - Summarizing the history of simulation training
for safety improvement, this review describes the current gap
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psnet.ahrq.gov/issue/intraoperative-patient-information-handover-between-anesthesia-providers
November 24, 2021 - Despite its low response rate, the study raises concerns that handoffs remain a safety gap in anesthesia
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psnet.ahrq.gov/node/35647/psn-pdf
June 25, 2010 - staffing options discussed,
and health care payers may provide the financial incentive to address this gap
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psnet.ahrq.gov/node/40853/psn-pdf
October 19, 2011 - Magnet hospitals appeared to be early adopters of the NQF practices, but over time, the gap between
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psnet.ahrq.gov/issue/coronavirus-ravaged-nursing-homes-inspectors-were-not-being-tested
October 14, 2020 - This story highlights a testing gap that has the potential to degrade efforts to minimize the spread
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psnet.ahrq.gov/issue/discontinuity-and-disaster-gaps-and-negotiation-culpability-medication-delivery
June 24, 2020 - Commentary
Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery.
Citation Text:
Dekker SWA. Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. J Law Med Ethics. 2007;35(3):463-70.
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psnet.ahrq.gov/issue/frailty-gaps-care-coordination-and-preventable-adverse-events
January 18, 2023 - Study
Frailty, gaps in care coordination, and preventable adverse events.
Citation Text:
Akinyelure OP, Colvin CL, Sterling MR, et al. Frailty, gaps in care coordination, and preventable adverse events. BMC Geriatr. 2022;22(1):476. doi:10.1186/s12877-022-03164-7.
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psnet.ahrq.gov/issue/typology-solutions-addressing-diagnostic-disparities-gaps-and-opportunities
November 02, 2022 - Study
Typology of solutions addressing diagnostic disparities: gaps and opportunities.
Citation Text:
Dukhanin V, Wiegand AA, Sheikh T, et al. Typology of solutions addressing diagnostic disparities: gaps and opportunities. Diagnosis (Berl). 2024;11(4):389-399. doi:10.1515/dx-2024-0026. …
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psnet.ahrq.gov/issue/holding-out-apology
January 19, 2024 - October 15, 2014
Medical error disclosure: the gap between attitude and practice.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.173_slideshow.ppt
April 01, 2008 - Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical Review 9. … Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical Review 9. … Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical Review 9.
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psnet.ahrq.gov/node/852808/psn-pdf
August 30, 2023 - urea nitrogen (BUN) to creatinine ratio of 15
(suggesting mild volume depletion), an elevated anion gap … s symptoms persisted, and she developed a progressively worsening metabolic acidosis with an
anion gap … The patient’s care was assumed by the obstetrics
team, and within 12 hours her anion gap was closed. … U: I’m uncomfortable with her anion gap increasing.
S: This is a patient safety issue.
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psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
January 01, 2023 - nitrogen (BUN) to creatinine ratio of 15 (suggesting mild volume depletion),
an elevated anion gap … symptoms persisted, and she developed a progressively
worsening metabolic acidosis with an anion gap … • The patient’s care was assumed by the obstetrics team, and within 12
hours her anion gap was closed … – U: I’m uncomfortable with her anion gap increasing.
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psnet.ahrq.gov/issue/2004-ashp-leadership-conference-pharmacy-practice-management-executive-summary-improving
June 16, 2019 - August 2, 2015
Bridging the gap between hospital and primary care: the pharmacist home
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psnet.ahrq.gov/node/37498/psn-pdf
April 30, 2014 - patterns-communication-breakdowns-resulting-injury-surgical-patients
https://psnet.ahrq.gov/issue/checklist
https://psnet.ahrq.gov/issue/bridging-communication-gap-operating-room-medical-team-training
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psnet.ahrq.gov/issue/health-information-technology-engaging-patients-diagnostic-decision-making-emergency
April 22, 2020 - This issue brief highlights health IT tools that can close this communication gap to engage patients
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psnet.ahrq.gov/issue/science-improvement
August 04, 2021 - approach to evidence-based evaluation of patient safety interventions that, if adopted, may bridge the gap
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psnet.ahrq.gov/node/40674/psn-pdf
October 16, 2012 - discharge, this study provides reinforcement for comprehensive interventions that attempt to
bridge the gap
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psnet.ahrq.gov/node/38760/psn-pdf
July 08, 2009 - The authors recommend several interventions,
including safety walk rounds, that could address this gap