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psnet.ahrq.gov/issue/medicare-payment-selected-adverse-events-building-business-case-investing-patient-safety
September 18, 2009 - Study
Medicare payment for selected adverse events: building the business case for investing in patient safety.
Citation Text:
Zhan C, Friedman B, Mosso A, et al. Medicare payment for selected adverse events: building the business case for investing in patient safety. Health Aff (Millw…
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psnet.ahrq.gov/issue/measuring-harm-and-informing-quality-improvement-welsh-nhs-longitudinal-welsh-national
October 12, 2016 - Book/Report
Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study.
Citation Text:
Mayor S, Baines E, Vincent CA, et al. Measuring Harm And Informing Quality Improvement In The Welsh Nhs: The Longitudinal Welsh National Adv…
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psnet.ahrq.gov/issue/association-between-state-medical-malpractice-environment-and-postoperative-outcomes-united
February 14, 2017 - Study
Association between state medical malpractice environment and postoperative outcomes in the United States.
Citation Text:
Minami CA, Sheils CR, Pavey E, et al. Association Between State Medical Malpractice Environment and Postoperative Outcomes in the United States. J Am Coll Surg.…
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psnet.ahrq.gov/issue/we-cant-get-along-without-each-other-qualitative-interviews-physicians-about-device-industry
March 07, 2018 - Study
"We can't get along without each other": qualitative interviews with physicians about device industry representatives, conflict of interest and patient safety.
Citation Text:
Gagliardi AR, Lehoux P, Ducey A, et al. "We can't get along without each other": Qualitative interviews wit…
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psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-facilities-fy-2020
September 10, 2014 - Book/Report
Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020.
Citation Text:
Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020. Washington, DC: Veterans Affairs Office of Inspector General; August …
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psnet.ahrq.gov/issue/understanding-diagnostic-errors-medicine-lesson-aviation
December 30, 2014 - Study
Understanding diagnostic errors in medicine: a lesson from aviation.
Citation Text:
Singh H, Petersen LA, Thomas EJ. Understanding diagnostic errors in medicine: a lesson from aviation. Qual Saf Health Care. 2006;15(3):159-64.
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psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd
May 01, 2016 - Did you hear any of that kind of feedback?
BD : All the time. Nurses have struggled with this. … They see the flashing numbers and hear the alarm sounds, and often the families who are visiting also … Imagine yourself as a patient in a hospital, doing relatively well, and in one 24-hour period you hear
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psnet.ahrq.gov/node/49595/psn-pdf
December 01, 2009 - shared adjective in superficial venous thrombosis and
SFV requires memorizing a rule: every time you hear
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psnet.ahrq.gov/issue/description-and-evaluation-adaptations-global-trigger-tool-enhance-value-adverse-event
November 23, 2014 - Study
Description and evaluation of adaptations to the Global Trigger Tool to enhance value to adverse event reduction efforts.
Citation Text:
Kennerly DA, Saldaña M, Kudyakov R, et al. Description and evaluation of adaptations to the global trigger tool to enhance value to adverse eve…
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psnet.ahrq.gov/issue/factors-associated-hospital-admission-after-outpatient-surgery-veterans-health-administration
August 17, 2018 - Study
Factors associated with hospital admission after outpatient surgery in the Veterans Health Administration.
Citation Text:
Mull HJ, Rosen AK, O'Brien WJ, et al. Factors Associated with Hospital Admission after Outpatient Surgery in the Veterans Health Administration. Health Serv Res…
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psnet.ahrq.gov/issue/multi-stakeholder-consensus-driven-research-agenda-better-understanding-and-supporting
September 01, 2018 - Commentary
A multi-stakeholder consensus-driven research agenda for better understanding and supporting the emotional impact of harmful events on patients and families.
Citation Text:
Bell SK, Etchegaray J, Gaufberg E, et al. A Multi-Stakeholder Consensus-Driven Research Agenda for Bette…
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psnet.ahrq.gov/issue/characterization-adverse-events-detected-large-health-care-delivery-system-using-enhanced
May 25, 2013 - Study
Characterization of adverse events detected in a large health care delivery system using an enhanced Global Trigger Tool over a five-year interval.
Citation Text:
Kennerly DA, Kudyakov R, da Graca B, et al. Characterization of adverse events detected in a large health care delivery…
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psnet.ahrq.gov/issue/speaking-about-care-concerns-icu-patient-and-family-experiences-attitudes-and-perceived
August 09, 2018 - Study
Emerging Classic
Speaking up about care concerns in the ICU: patient and family experiences, attitudes and perceived barriers.
Citation Text:
Bell SK, Roche S, Mueller A, et al. Speaking up about care concerns in the ICU: patient and family experiences, at…
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psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md
December 01, 2009 - GH: One of the things we often hear when we provide feedback to high-malpractice-risk physicians is … And I hear you. But in my heart of hearts, let's say I really don't want to know. … I worry when I hear the sound bite "sorry works"—an apology is powerful when superimposed on a patient–professional … Did you ever hear that before?
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psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
December 01, 2009 - GH: One of the things we often hear when we provide feedback to high-malpractice-risk physicians is … And I hear you. But in my heart of hearts, let's say I really don't want to know. … I worry when I hear the sound bite "sorry works"—an apology is powerful when superimposed on a patient–professional … Did you ever hear that before?
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psnet.ahrq.gov/curated-library/maternal-safety
January 31, 2024 - Read More
HEAR Her Concerns. … Multi-use Website
HEAR Her Concerns.
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psnet.ahrq.gov/issue/use-unsolicited-patient-observations-identify-surgeons-increased-risk-postoperative
July 10, 2019 - Study
Classic
Use of unsolicited patient observations to identify surgeons with increased risk for postoperative complications.
Citation Text:
Cooper WO, Guillamondegui O, Hines J, et al. Use of Unsolicited Patient Observations to Identify Surgeons With Increase…
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psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
May 01, 2016 - Imagine yourself as a patient in a hospital, doing relatively well, and in one 24-hour period you hear … Did you hear any of that kind of feedback?
BD : All the time. Nurses have struggled with this. … They see the flashing numbers and hear the alarm sounds, and often the families who are visiting also
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psnet.ahrq.gov/node/33866/psn-pdf
September 01, 2018 - We hear a lot about the constraints of short visits and pressed
clinicians that cannot take just one … When we hear resistance to the concept of OpenNotes, we
realize it's often not really resistance to … When people hear about OpenNotes, many
say, "Wow, this is a great intervention for tech-savvy patients
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psnet.ahrq.gov/node/841566/psn-pdf
December 14, 2022 - I would love to hear a little bit more about how CMS is integrating patient voices into
the measurement … By law, there is a 60-day public
comment period in rule writing, and we hear comments from the public … The more we hear from patients, caregivers, individuals, and communities about their care, then the better