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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40649/psn-pdf
    April 21, 2015 - Explaining Michigan: developing an ex post theory of a quality improvement program. April 21, 2015 Dixon-Woods M, Bosk CL, Aveling EL, et al. Explaining Michigan: developing an ex post theory of a quality improvement program. Milbank Q. 2011;89(2):167-205. doi:10.1111/j.1468-0009.2011.00625.x. https://psnet.ahrq.g…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854636/psn-pdf
    October 18, 2023 - Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising. October 18, 2023 Young RA, Gurses AP, Fulda KG, et al. Primary care teams’ reported actions to improve medication safety: a qualitative study with insights in high reliability organi…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42001/psn-pdf
    August 02, 2015 - Diagnostic inaccuracy of smartphone applications for melanoma detection. August 2, 2015 Wolf JA, Moreau JF, Akilov O, et al. Diagnostic inaccuracy of smartphone applications for melanoma detection. JAMA Dermatol. 2013;149(4):422-426. doi:10.1001/jamadermatol.2013.2382. https://psnet.ahrq.gov/issue/diagnostic-inacc…

  4. | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/publications/search.html?page=19
    October 01, 2003 - Search Publications The Agency for Healthcare Research and Quality (AHRQ)'s publications offer practical information to help a variety of health care organizations, providers, and others make care safer in all health care settings. 191 - 191 of 191 Publications displayed Find Publications by Keyword or To…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40254/psn-pdf
    September 19, 2016 - Medical error: the second victim. September 19, 2016 Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320(7237):726-727. https://psnet.ahrq.gov/issue/medical-error-second-victim This editorial coined the term "second victim" to describe clinicians who commit error…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47573/psn-pdf
    December 19, 2018 - Can communication-and-resolution programs achieve their potential? Five key questions. December 19, 2018 Gallagher TH, Mello MM, Sage WM, et al. Can Communication-And-Resolution Programs Achieve Their Potential? Five Key Questions. Health Aff (Millwood). 2018;37(11):1845-1852. doi:10.1377/hlthaff.2018.0727. https…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836926/psn-pdf
    April 13, 2022 - Overall performance of a drug-drug interaction clinical decision support system: quantitative evaluation and end- user survey. April 13, 2022 Van De Sijpe G, Quintens C, Walgraeve K, et al. Overall performance of a drug–drug interaction clinical decision support system: quantitative evaluation and end-user survey.…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50773/psn-pdf
    January 08, 2020 - Effect of cognitive aids on adherence to best practice in the treatment of deteriorating surgical patients: a randomized clinical trial in a simulation setting. January 8, 2020 Koers L, van Haperen M, Meijer CGF, et al. Effect of Cognitive Aids on Adherence to Best Practice in the Treatment of Deteriorating Surgic…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42619/psn-pdf
    January 23, 2019 - High-reliability health care: getting there from here. January 23, 2019 Chassin MR, Loeb JM. High-reliability health care: getting there from here. Milbank Q. 2013;91(3):459-490. doi:10.1111/1468-0009.12023. https://psnet.ahrq.gov/issue/high-reliability-health-care-getting-there-here Aviation is often cited as an …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866189/psn-pdf
    June 26, 2024 - Listen to me, I really am sick! Patient and family narratives of clinical deterioration before and during rapid response system intervention. June 26, 2024 Bucknall TK, Guinane J, McCormack B, et al. Listen to me, I really am sick! Patient and family narratives of clinical deterioration before and during rapid res…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46309/psn-pdf
    December 22, 2018 - Effects of the I-PASS nursing handoff bundle on communication quality and workflow. December 22, 2018 Starmer AJ, Schnock KO, Lyons A, et al. Effects of the I-PASS Nursing Handoff Bundle on communication quality and workflow. BMJ Qual Saf. 2017;26(12):949-957. doi:10.1136/bmjqs-2016-006224. https://psnet.ahrq.gov/…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837210/psn-pdf
    May 25, 2022 - A learning health system agenda for organizational approaches to enhancing occupational well-being among clinicians. May 25, 2022 Rotenstein LS, Melnick ER, Sinsky CA. A learning health system agenda for organizational approaches to enhancing occupational well-being among clinicians. JAMA. 2022;327(21):2079-2080. …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837795/psn-pdf
    August 10, 2022 - Role of the regulator in enabling a just culture: a qualitative study in mental health and hospital care. August 10, 2022 Weenink J-W, Wallenburg I, Hartman L, et al. Role of the regulator in enabling a just culture: a qualitative study in mental health and hospital care. BMJ Open. 2022;12(7):e061321. doi:10.1136/b…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45708/psn-pdf
    October 31, 2017 - Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU. October 31, 2017 Bates KE, Shea JA, Bird GL, et al. Development and Preliminary Testing of the Coordination Process Error Re…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47382/psn-pdf
    August 29, 2018 - Parenteral opioid shortage—treating pain during the opioid-overdose epidemic. August 29, 2018 Bruera E. Parenteral Opioid Shortage - Treating Pain during the Opioid-Overdose Epidemic. N Engl J Med. 2018;379(7):601-603. doi:10.1056/NEJMp1807117. https://psnet.ahrq.gov/issue/parenteral-opioid-shortage-treating-pain-…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46024/psn-pdf
    June 15, 2017 - Introductions during time-outs: do surgical team members know one another's names? June 15, 2017 Birnbach DJ, Rosen LF, Fitzpatrick M, et al. Introductions during time-outs: do surgical team members know one another's names? Jt Comm J Qual Patient Saf. 2017;43(6):284-288. doi:10.1016/j.jcjq.2017.03.001. https://p…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72521/psn-pdf
    December 02, 2020 - I-PASS illness diversity identifies patients at risk for overnight clinical deterioration. December 2, 2020 Shah C, Sanber K, Jacobson R, et al. I-PASS illness diversity identifies patients at risk for overnight clinical deterioration. J Grad Med Educ. 2020;12(5):578-582. doi:10.4300/jgme-d-19-00755.1. https://psn…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45350/psn-pdf
    October 21, 2016 - A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. October 21, 2016 National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press; 2016. https://psnet.ahrq.gov/issue/national-trauma-care-system-inte…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837640/psn-pdf
    July 06, 2022 - Identifying and reconciling patients' allergy information within the electronic health record. July 6, 2022 Vallamkonda S, Ortega CA, Lo YC, et al. Identifying and reconciling patients' allergy information within the electronic health record. Stud Health Technol Inform. 2022;290:120-124. doi:10.3233/shti220044. ht…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36237/psn-pdf
    September 12, 2011 - An empirically derived taxonomy of factors affecting physicians' willingness to disclose medical errors. September 12, 2011 Kaldjian LC, Jones EW, Rosenthal GE, et al. An empirically derived taxonomy of factors affecting physicians’ willingness to disclose medical errors. J Gen Intern Med. 2007;21(9). doi:10.1007/b…
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