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psnet.ahrq.gov/issue/applying-universal-protocol-improve-patient-safety-radiology-services
March 27, 2018 - Providers
Quality and Safety Professionals
Radiology
Identification Errors
Discontinuities, Gaps
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psnet.ahrq.gov/web-mm/it-safe-be-direct
September 30, 2015 - direct admission process can be complex and, like all complex systems, can be aggravated by inherent gaps … Gaps in the continuity of care and progress on patient safety. BMJ. 2000;320:791-794. … See More About The Topic
Hospitals
Gynecology
Cardiology
Discontinuities, Gaps
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psnet.ahrq.gov/web-mm/fumbled-handoff
September 01, 2006 - between institutions or between the inpatient and outpatient setting, in-hospital signouts represent gaps … patients at increased risk for harm.( 3 ) Although practitioners are generally effective in bridging gaps … Gaps in the continuity of care and progress on patient safety.
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psnet.ahrq.gov/node/46029/psn-pdf
October 11, 2017 - Closing the gap and raising the bar: assessing board
competency in quality and safety.
October 11, 2017
McGaffigan PA, Ullem BD, Gandhi TK. Closing the Gap and Raising the Bar: Assessing Board
Competency in Quality and Safety. Jt Comm J Qual Patient Saf. 2017;43(6):267-274.
doi:10.1016/j.jcjq.2017.03.003.
https:/…
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psnet.ahrq.gov/node/73200/psn-pdf
April 28, 2021 - A Sweet Case of Hidden Hydrogen Ions
April 28, 2021
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
The Case
A?24-year-old, Arabic-speaking?woman?with a history of type 1?diabetes?mellitus, gastroparesis,?and
severe e…
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psnet.ahrq.gov/node/43998/psn-pdf
May 28, 2015 - Bridging the gap between hospital and primary care: the
pharmacist home visit.
May 28, 2015
Ensing HT, Koster ES, Stuijt CCM, et al. Bridging the gap between hospital and primary care: the
pharmacist home visit. Int J Clin Pharm. 2015;37(3):430-4. doi:10.1007/s11096-015-0093-4.
https://psnet.ahrq.gov/issue/bridgin…
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psnet.ahrq.gov/node/837038/psn-pdf
May 04, 2022 - Mind the Implementation Gap. The Persistence of
Avoidable Harm in the NHS.
May 4, 2022
London UK: Patient Safety Learning: 2022.
https://psnet.ahrq.gov/issue/mind-implementation-gap-persistence-avoidable-harm-nhs
Unsafe care affects a wide range of individuals and organizations physically, emotionally, and financi…
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psnet.ahrq.gov/node/849606/psn-pdf
May 31, 2023 - The Patient Safety Adoption Framework: a practical
framework to bridge the know-do gap.
May 31, 2023
Moyal-Smith R, Margo J, Maloney FL, et al. J Patient Saf. 2023;19(4):243-248.
https://psnet.ahrq.gov/issue/patient-safety-adoption-framework-practical-framework-bridge-know-do-gap
Individual, team, and organization…
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psnet.ahrq.gov/issue/i-pass-checklist-powerful-tool-patient-handoffs
November 21, 2018 - See More About The Topic
Outpatient Pharmacy
Pharmacists
Pharmacy
Discontinuities, Gaps
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psnet.ahrq.gov/node/47456/psn-pdf
April 30, 2019 - ISMP Gap Analysis Tool (GAT) for Safe IV Push
Medication Practices.
April 30, 2019
Horsham, PA: Institute for Safe Medication Practices; 2018.
https://psnet.ahrq.gov/issue/ismp-gap-analysis-tool-gat-safe-iv-push-medication-practices
Standardized practices have not been uniformly adopted to support safe IV medicati…
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psnet.ahrq.gov/issue/real-time-debriefing-after-critical-events-exploring-gap-between-principle-and-reality
December 15, 2021 - Review
Emerging Classic
Real-time debriefing after critical events: exploring the gap between principle and reality.
Citation Text:
Arriaga AF, Szyld D, Pian-Smith MCM. Real-time debriefing after critical events: exploring the gap between principle and reality. …
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psnet.ahrq.gov/issue/patient-safety-5
February 22, 2006 - More
See More About The Topic
Quality and Safety Professionals
Discontinuities, Gaps
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psnet.ahrq.gov/issue/patient-safety-measures-complications
March 23, 2012 - More About The Topic
Quality and Safety Professionals
Safety Scientists
Discontinuities, Gaps
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psnet.ahrq.gov/issue/aftercare-tips-patients-checking-out-hospital
February 09, 2011 - View More
See More About The Topic
Hospitals
Patients
Discontinuities, Gaps
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psnet.ahrq.gov/print/pdf/node/848754
January 01, 2025 - the hospital and home can jeopardize patient safety for a myriad of reasons,
such as communication gaps … the hospital and home can jeopardize patient safety for a myriad of reasons,
such as communication gaps
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psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - A Sweet Case of Hidden Hydrogen Ions
Citation Text:
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 X…
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psnet.ahrq.gov/issue/bridging-gap-framework-and-strategies-integrating-quality-and-safety-mission-teaching
April 24, 2018 - Commentary
Bridging the gap: a framework and strategies for integrating the quality and safety mission of teaching hospitals and graduate medical education.
Citation Text:
Tess A, Vidyarthi A, Yang J, et al. Bridging the Gap: A Framework and Strategies for Integrating the Quality and Saf…
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psnet.ahrq.gov/node/41003/psn-pdf
April 16, 2018 - Gap assessment of hospitals' adoption of the just culture
principles.
April 16, 2018
Barger DM; Marella W; Charney FJ.
https://psnet.ahrq.gov/issue/gap-assessment-hospitals-adoption-just-culture-principles
This article reports that Pennsylvania health care organizations overestimated their adoption of just culture…
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psnet.ahrq.gov/node/38864/psn-pdf
July 08, 2013 - Addressing the quality and safety gap—parts I-III.
July 8, 2013
Princeton, NJ: Robert Wood Johnson Foundation; November 2010.
https://psnet.ahrq.gov/issue/addressing-quality-and-safety-gap-parts-i-iii
Part I of this three-part series examines the quality improvement experience of four health care
organizations and…
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psnet.ahrq.gov/node/46055/psn-pdf
July 26, 2017 - Bridging the gap between work-as-imagined and work-as-
done.
July 26, 2017
Deutsch ES. PA-PSRS Patient Saf Advis. June 2017;14:80-83.
https://psnet.ahrq.gov/issue/bridging-gap-between-work-imagined-and-work-done
Understanding what is possible in the context of frontline practice is key when designing enhancements …