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psnet.ahrq.gov/issue/evidence-based-interventions-reduce-adverse-events-hospitals-systematic-review-systematic
December 04, 2015 - Review
Evidence-based interventions to reduce adverse events in hospitals: a systematic review of systematic reviews.
Citation Text:
Zegers M, Hesselink G, Geense W, et al. Evidence-based interventions to reduce adverse events in hospitals: a systematic review of systematic reviews. BMJ …
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psnet.ahrq.gov/issue/impact-health-information-management-professionals-patient-safety-systematic-review
August 25, 2021 - Review
The impact of health information management professionals on patient safety: a systematic review.
Citation Text:
Kemp T, Butler‐Henderson K, Allen P, et al. The impact of health information management professionals on patient safety: a systematic review. Health Info Libr J. 2021;3…
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psnet.ahrq.gov/issue/embracing-multiple-aims-healthcare-improvement-and-innovation
June 24, 2020 - Commentary
Embracing multiple aims in healthcare improvement and innovation.
Citation Text:
Amalberti R, Staines A, Vincent CA. Embracing multiple aims in healthcare improvement and innovation. Int J Qual Health Care. 2022;34(1):mzac006. doi:10.1093/intqhc/mzac006.
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Fo…
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psnet.ahrq.gov/issue/operational-measurement-diagnostic-safety-state-science-0
September 28, 2022 - Commentary
Emerging Classic
Operational measurement of diagnostic safety: state of the science.
Citation Text:
Singh H, Bradford A, Goeschel CA. Operational measurement of diagnostic safety: state of the science. Diagnosis (Berl). 2021;8(1):51-66. doi:10.1515/dx…
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psnet.ahrq.gov/issue/using-learning-communities-support-adoption-health-care-innovations
March 15, 2017 - Commentary
Using learning communities to support adoption of health care innovations.
Citation Text:
Carpenter D, Hassell S, Mardon R, et al. Using Learning Communities to Support Adoption of Health Care Innovations. Jt Comm J Qual Patient Saf. 2018;44(10):566-573. doi:10.1016/j.jcjq.201…
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psnet.ahrq.gov/node/33590/psn-pdf
September 15, 2024 - Leadership Role in Improving Safety
September 15, 2024
Leadership Role in Improving Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/leadership-role-improving-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and p…
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psnet.ahrq.gov/issue/doing-detective-work-find-cancer-how-are-non-specific-symptom-pathways-cancer-investigation
April 05, 2023 - Commentary
Doing 'detective work' to find a cancer: how are non-specific symptom pathways for cancer investigation organised, and what are the implications for safety and quality of care? A multisite qualitative approach.
Citation Text:
Black GB, Nicholson BD, Moreland J-A, et al. Doing …
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psnet.ahrq.gov/issue/board-bedside-how-application-financial-structures-safety-and-quality-can-drive
January 29, 2015 - Study
From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system.
Citation Text:
Austin M, Demski R, Callender T, et al. From Board to Bedside: How the Application of Financial Structures to Safety and Q…
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psnet.ahrq.gov/issue/culture-and-behaviour-english-national-health-service-overview-lessons-large-multimethod
May 01, 2015 - Study
Classic
Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study.
Citation Text:
Dixon-Woods M, Baker R, Charles K, et al. Culture and behaviour in the English National Health Service: overview of les…
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psnet.ahrq.gov/issue/prone-score-algorithm-predicting-doctors-risks-formal-patient-complaints-using-routinely
September 07, 2011 - Study
The PRONE score: an algorithm for predicting doctors' risks of formal patient complaints using routinely collected administrative data.
Citation Text:
Spittal MJ, Bismark M, Studdert DM. The PRONE score: an algorithm for predicting doctors' risks of formal patient complaints using …
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psnet.ahrq.gov/node/36054/psn-pdf
November 10, 2011 - Our broken health care system and how to fix it: an essay
on health law and policy.
November 10, 2011
Jost TS. Wake Forest Law Rev. 2006;41:537-618.
https://psnet.ahrq.gov/issue/our-broken-health-care-system-and-how-fix-it-essay-health-law-and-policy
The author discusses problems in the U.S. health care system and…
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psnet.ahrq.gov/node/35425/psn-pdf
June 17, 2014 - Have you M.E.T. the future of better patient safety?
June 17, 2014
Larson L. Have you M.E.T. the future of better patient safety? Trustee : the journal for hospital governing
boards. 2005;58(8):6-10, 1.
https://psnet.ahrq.gov/issue/have-you-met-future-better-patient-safety
This article recaps the origins of the me…
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psnet.ahrq.gov/issue/world-health-organization-world-federation-societies-anaesthesiologists-who-wfsa
November 16, 2015 - These standards provide guidance and recommendations for clinicians, administrators, and governments
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psnet.ahrq.gov/issue/good-bad-and-ugly-what-do-we-really-do-when-we-identify-best-and-worst-organisations
August 20, 2018 - Governments and organizations frequently identify high- and low-performing healthcare organizations
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psnet.ahrq.gov/node/39191/psn-pdf
February 08, 2011 - Leadership in Healthcare Organizations: A Guide to Joint
Commission Leadership Standards.
February 8, 2011
Schyve PM. San Diego, CA: Governance Institute; 2009.
https://psnet.ahrq.gov/issue/leadership-healthcare-organizations-guide-joint-commission-leadership-
standards
This white paper provides comprehensive inf…
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psnet.ahrq.gov/issue/patient-safety-and-problem-many-hands
June 16, 2021 - Commentary
Patient safety and the problem of many hands.
Citation Text:
Dixon-Woods M, Pronovost P. Patient safety and the problem of many hands. BMJ Qual Saf. 2016;25(7):485-488. doi:10.1136/bmjqs-2016-005232.
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Format:
DOI Google Scholar PubMed BibTeX EndNote …
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psnet.ahrq.gov/node/50715/psn-pdf
December 04, 2019 - Quality and Safety of Healthcare in Switzerland.
December 4, 2019
Vincent C, Staines A. Bern, Switzerland: Federal Department of Home Affairs, Federal Office of Public
Health; 2019.
https://psnet.ahrq.gov/issue/quality-and-safety-healthcare-switzerland
Patient safety is a goal for countries worldwide. This report …
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psnet.ahrq.gov/node/45672/psn-pdf
January 01, 2025 - Healthcare Simulation Dictionary, Third Edition.
December 10, 2024
Lioce L, Lopreiato J, Anderson M, et al, eds and the Terminology and Concepts Working Group. Rockville,
MD: Agency for Healthcare Research and Quality; January 2025. AHRQ Publication No. 24-0077.
https://psnet.ahrq.gov/issue/healthcare-simulation-di…
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psnet.ahrq.gov/node/46620/psn-pdf
January 30, 2018 - Where should patient safety be installed?
January 30, 2018
Sine DM, Paull D. Where should patient safety be installed? J Healthc Risk Manag. 2017;37(3):14-17.
doi:10.1002/jhrm.21285.
https://psnet.ahrq.gov/issue/where-should-patient-safety-be-installed
Organizational structure influences the prioritization of safe…
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psnet.ahrq.gov/node/837774/psn-pdf
August 03, 2022 - Preventing retained surgical items.
August 3, 2022
Weston M, Chiodo C. Preventing retained surgical items. AORN J. 2022;115(6):569-575.
doi:10.1002/aorn.13697.
https://psnet.ahrq.gov/issue/preventing-retained-surgical-items
Unintentionally retained foreign objects can be exacerbated by fatigue, distractions, and c…