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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47508/psn-pdf
    October 24, 2018 - Root cause analysis of reported patient falls in ORs in the Veterans Health Administration. October 24, 2018 Soncrant CM, Warner LJ, Neily J, et al. Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration. AORN J. 2018;108(4):386-397. doi:10.1002/aorn.12372. https://psnet.ahrq.go…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843085/psn-pdf
    January 25, 2023 - Assessment of the use of patient vital sign data for preventing misidentification and medical errors. January 25, 2023 Maul J, Straub J. Assessment of the use of patient vital sign data for preventing misidentification and medical errors. Healthcare (Basel). 2022;10(12):2440. doi:10.3390/healthcare10122440. https:…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74008/psn-pdf
    October 27, 2021 - Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds. October 27, 2021 Klimmeck S, Sexton B, Schwendimann R. Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds. Jt Comm J Qual Patient Saf. 2021;47(12):783-792. …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47001/psn-pdf
    August 17, 2018 - Realist synthesis of intentional rounding in hospital wards: exploring the evidence of what works, for whom, in what circumstances and why. August 17, 2018 Sims S, Leamy M, Davies N, et al. Realist synthesis of intentional rounding in hospital wards: exploring the evidence of what works, for whom, in what circumst…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37468/psn-pdf
    April 11, 2011 - Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes. April 11, 2011 Hunt EA, Walker AR, Shaffner DH, et al. Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the fir…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46133/psn-pdf
    May 24, 2017 - Implementing smart infusion pumps with dose-error reduction software: real-world experiences. May 24, 2017 Heron C. Implementing smart infusion pumps with dose-error reduction software: real-world experiences. Br J Nurs. 2017;26(8):S13-S16. doi:10.12968/bjon.2017.26.8.S13. https://psnet.ahrq.gov/issue/implementing…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74187/psn-pdf
    December 15, 2021 - Real-world virtual patient simulation to improve diagnostic performance through deliberate practice: a prospective quasi-experimental study. December 15, 2021 Kotwal S, Fanai M, Fu W, et al. Real-world virtual patient simulation to improve diagnostic performance through deliberate practice: a prospective quasi-exp…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34694/psn-pdf
    February 10, 2011 - Computerized surveillance of adverse drug events in hospital patients. February 10, 2011 Classen DC, Pestotnik SL, Evans RS, et al. Computerized surveillance of adverse drug events in hospital patients. JAMA. 1991;266(20):2847-51. https://psnet.ahrq.gov/issue/computerized-surveillance-adverse-drug-events-hospital-…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47143/psn-pdf
    January 30, 2019 - E-learning on risk management. An opportunity for sharing knowledge and experiences in patient safety. January 30, 2019 Agra Y, García-Álvarez V, Aibar-Remón C, et al. E-learning on risk management. An opportunity for sharing knowledge and experiences in patient safety. Int J Health Care Qual. 2019;31(8):639-646. …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850163/psn-pdf
    June 07, 2023 - Managing near-miss reporting in hospitals: the dynamics between staff members’ willingness to report and management’s handling of near-miss events. June 7, 2023 Caspi H, Perlman Y, Westreich S. Managing near-miss reporting in hospitals: the dynamics between staff members’ willingness to report and management’s han…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50933/psn-pdf
    February 26, 2020 - Medication-related harm in older adults following hospital discharge: development and validation of a prediction tool. February 26, 2020 Parekh N, Ali K, Davies JG, et al. Medication-related harm in older adults following hospital discharge: development and validation of a prediction tool. BMJ Qual Saf. 2020;29(2)…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866344/psn-pdf
    January 01, 2025 - Machine learning evaluation of inequities and disparities associated with nurse sensitive indicator safety events. July 24, 2024 Georgantes ER, Gunturkun F, McGreevy TJ, et al. Machine learning evaluation of inequities and disparities associated with nurse sensitive indicator safety events. J Nurs Scholarsh. 2025;5…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46715/psn-pdf
    May 02, 2018 - Filling the gap: simulation-based crisis resource management training for emergency medicine residents. May 2, 2018 Parsons JR, Crichlow A, Ponnuru S, et al. Filling the gap: simulation-based crisis resource management training for emergency medicine residents. West J Emerg Med. 2018;19(1):205-210. doi:10.5811/wes…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44844/psn-pdf
    March 02, 2016 - From To Err Is Human to Improving Diagnosis in Health Care: the risk management perspective. March 2, 2016 Bunting RF, Groszkruger DP. From To Err Is Human to Improving Diagnosis in Health Care: The risk management perspective. J Healthc Risk Manag. 2016;35(3):10-23. doi:10.1002/jhrm.21205. https://psnet.ahrq.gov/…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47042/psn-pdf
    June 13, 2018 - Addressing dual patient and staff safety through a team- based standardized patient simulation for agitation management in the emergency department. June 13, 2018 Wong AH, Auerbach MA, Ruppel H, et al. Addressing Dual Patient and Staff Safety Through A Team- Based Standardized Patient Simulation for Agitation Mana…

  16. Comparing Health Plan and Provider Quality Scores to Each Other | Agency for Healthcare Research and Quality

    www.ahrq.gov/talkingquality/translate/compare/choose/compare-providers.html
    January 01, 2023 - Comparing Health Plan and Provider Quality Scores to Each Other The simplest and most common strategy is to compare each entity’s performance to the average performance of all the entities you are rating. Advantages of Comparing to the Community Average You have all the information you need to make the co…

  17. How to Map Workflows in Health Care Settings | Agency for Healthcare Research and Quality

    www.ahrq.gov/evidencenow/tools/workflow-mapping.html
    February 01, 2025 - How to Map Workflows in Health Care Settings Resource: Mapping and Redesigning Workflow  (PDF, 8.8 MB, 69 (Including 54 pages of slides in appendices) pages) Part of an AHRQ curriculum used to train practice facilitators, this resource explains the purpose and process of workflow mapping in a primary care se…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73914/psn-pdf
    October 06, 2021 - Is there a mismatch between the perspectives of patients and regulators on healthcare quality? A survey study. October 6, 2021 Bouwman R, Bomhoff M, Robben PB, et al. Is there a mismatch between the perspectives of patients and regulators on healthcare quality? A survey study. J Patient Saf. 2021;17(7):473-482. do…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72476/psn-pdf
    November 18, 2020 - Maintaining perioperative safety in uncertain times: COVID-19 pandemic response strategies. November 18, 2020 Mazzola SM, Grous C. Maintaining perioperative safety in uncertain times: COVID-19 pandemic response strategies. AORN J. 2020;112(4):397-405. doi:10.1002/aorn.13195. https://psnet.ahrq.gov/issue/maintainin…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46103/psn-pdf
    September 23, 2017 - Polypharmacy in the elderly--when good drugs lead to bad outcomes: a teachable moment. September 23, 2017 Carroll C, Hassanin A. Polypharmacy in the Elderly-When Good Drugs Lead to Bad Outcomes: A Teachable Moment. JAMA Intern Med. 2017;177(6):871. doi:10.1001/jamainternmed.2017.0911. https://psnet.ahrq.gov/issue/…
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