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psnet.ahrq.gov/node/47315/psn-pdf
August 01, 2018 - Agent of change.
August 1, 2018
Gale SF. Chief Learning Officer. July/August 2018;17:22-25.
https://psnet.ahrq.gov/issue/agent-change
Organizational learning is an essential element of safety culture. This article reports how one hospital
leader drew from the success of aviation strategies to design and implement …
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psnet.ahrq.gov/node/36456/psn-pdf
May 27, 2011 - Evaluation and certification of computerized physician
order entry systems.
May 27, 2011
Classen D, Avery A, Bates DW. Evaluation and certification of computerized provider order entry systems.
J Am Med Inform Assoc. 2007;14(1):48-55.
https://psnet.ahrq.gov/issue/evaluation-and-certification-computerized-physician…
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psnet.ahrq.gov/node/36431/psn-pdf
March 28, 2011 - Using the internet to deliver education on drug safety.
March 28, 2011
Franklin B, O'Grady K, Parr J, et al. Using the internet to deliver education on drug safety. Qual Saf Health
Care. 2006;15(5):329-33.
https://psnet.ahrq.gov/issue/using-internet-deliver-education-drug-safety
The project team implemented a web-…
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psnet.ahrq.gov/node/38726/psn-pdf
July 13, 2009 - Physician Quality Officer: a new model for engaging
physicians in quality improvement.
July 13, 2009
Walsh KE, Ettinger WH, Klugman R. Physician quality officer: a new model for engaging physicians in
quality improvement. Am J Med Qual. 2009;24(4):295-301. doi:10.1177/1062860609336219.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/37951/psn-pdf
May 26, 2011 - The Leapfrog Group's CPOE standard and evaluation tool.
May 26, 2011
Metzger JB, Welebob E, Turisco F, et al. Patient Saf Qual Healthc. July/August
2008;5:22-25.
https://psnet.ahrq.gov/issue/leapfrog-groups-cpoe-standard-and-evaluation-tool
This article describes an evaluation tool designed for…
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psnet.ahrq.gov/node/34622/psn-pdf
March 17, 2011 - National Confidential Enquiry into Patient Outcome and
Death.
March 17, 2011
National Confidential Enquiry into Patient Outcome and Death; NCEPOD
https://psnet.ahrq.gov/issue/national-confidential-enquiry-patient-outcome-and-death
Launched under the title National Confidential Enquiry into Perioperative Deaths (NC…
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psnet.ahrq.gov/node/37634/psn-pdf
February 15, 2011 - Simulation-based training for patient safety: 10 principles
that matter.
February 15, 2011
Salas E, Wilson KA, Lazzara EH, et al. Simulation-Based Training for Patient Safety. J Patient Saf.
2008;4(1). doi:10.1097/pts.0b013e3181656dd6.
https://psnet.ahrq.gov/issue/simulation-based-training-patient-safety-10-princi…
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psnet.ahrq.gov/node/38341/psn-pdf
April 02, 2009 - CPOE: it don't come easy.
April 2, 2009
Anderson HJ. CPOE: it don't come easy. Health Data Manag. 2009;17(1):18-20, 22, 24 passim.
https://psnet.ahrq.gov/issue/cpoe-it-dont-come-easy
Although shifting from paper-based or verbal orders to computerized physician order entry (CPOE)
systems could reduce medical errors…
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psnet.ahrq.gov/node/35354/psn-pdf
September 28, 2005 - Crew resource management training--clinicians' reactions
and attitudes.
September 28, 2005
France DJ, Stiles RA, Gaffney FA, et al. Crew resource management training-Clinicians' reactions and
attitudes. AORN J. 2006;82(2):213-224. doi:10.1016/s0001-2092(06)60313-x.
https://psnet.ahrq.gov/issue/crew-resource-manage…
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psnet.ahrq.gov/node/38024/psn-pdf
August 27, 2008 - Promoting patient safety using an early warning scoring
system.
August 27, 2008
Higgins Y, Maries-Tillott C, Quinton S, et al. Promoting patient safety using an early warning scoring
system. Nurs Stand. 2008;22(44):35-40.
https://psnet.ahrq.gov/issue/promoting-patient-safety-using-early-warning-scoring-system
Imp…
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psnet.ahrq.gov/node/39811/psn-pdf
September 13, 2010 - Disclosure of medical errors: the right thing to do.
September 13, 2010
Schuer KM, AAPA QCC of the. Disclosure of medical errors: the right thing to do. JAAPA. 2010;23(8):27-9.
https://psnet.ahrq.gov/issue/disclosure-medical-errors-right-thing-do
This article discusses medical error disclosure, provides evidence of…
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psnet.ahrq.gov/node/35119/psn-pdf
November 03, 2015 - Patient safety and health information technology
conference: A newsmaker interview with Carolyn M.
Clancy, MD.
November 3, 2015
Barclay L.
https://psnet.ahrq.gov/issue/patient-safety-and-health-information-technology-conference-newsmaker-
interview-carolyn-m
In this interview, Agency for Healthcare Research and …
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psnet.ahrq.gov/node/42030/psn-pdf
April 18, 2013 - Reducing hospital errors: interventions that build safety
culture.
April 18, 2013
Singer SJ, Vogus TJ. Reducing hospital errors: interventions that build safety culture. Annu Rev Public
Health. 2013;34:373-96. doi:10.1146/annurev-publhealth-031912-114439.
https://psnet.ahrq.gov/issue/reducing-hospital-errors-inter…
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psnet.ahrq.gov/node/40138/psn-pdf
July 21, 2011 - Decision support and patient safety: the time has come.
July 21, 2011
Hasley SK. Decision support and patient safety: the time has come. Am J Obstet Gynecol.
2011;204(6):461-5. doi:10.1016/j.ajog.2010.10.901.
https://psnet.ahrq.gov/issue/decision-support-and-patient-safety-time-has-come
This review reveals how dec…
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psnet.ahrq.gov/node/34718/psn-pdf
August 05, 2008 - How can we save the next victim?
August 5, 2008
Belkin L
https://psnet.ahrq.gov/issue/how-can-we-save-next-victim
In this article, Belkin examines how the medical field has recently shifted away from blaming individuals for
medical error toward a model that searches for systems problems and solutions for preventio…
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psnet.ahrq.gov/node/47053/psn-pdf
May 23, 2018 - TeamSTEPPS Canada.
May 23, 2018
Canadian Patient Safety Institute.
https://psnet.ahrq.gov/issue/teamstepps-canada
The TeamSTEPPS program was developed to support effective communication and teamwork skills in
various health care settings. This site supports the Canadian TeamSTEPPS initiative. The program will
pre…
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psnet.ahrq.gov/node/43534/psn-pdf
January 22, 2016 - Creating a fellowship curriculum in patient safety and
quality.
January 22, 2016
Abookire SA, Gandhi TK, Kachalia A, et al. Creating a Fellowship Curriculum in Patient Safety and Quality.
Am J Med Qual. 2016;31(1):27-30. doi:10.1177/1062860614549012.
https://psnet.ahrq.gov/issue/creating-fellowship-curriculum-pati…
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psnet.ahrq.gov/node/37247/psn-pdf
December 15, 2011 - Perinatal clinical decision support system: a
documentation tool for patient safety.
December 15, 2011
Provost C, Gray M. Perinatal clinical decision support system: a documentation tool for patient safety. Nurs
Womens Health. 2007;11(4):407-10.
https://psnet.ahrq.gov/issue/perinatal-clinical-decision-support-syst…
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psnet.ahrq.gov/node/36939/psn-pdf
September 09, 2011 - Internal reporting system to improve a pharmacy's
medication distribution process.
September 9, 2011
Rickrode GA, Williams-Lowe ME, Rippe JL, et al. Internal reporting system to improve a pharmacy's
medication distribution process. Am J Health Syst Pharm. 2007;64(11):1197-202.
https://psnet.ahrq.gov/issue/internal…
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psnet.ahrq.gov/node/45583/psn-pdf
January 18, 2017 - ASHP IV Adult Continuous Infusions.
January 18, 2017
Bethesda, MD: American Society of Health-System Pharmacists; 2016.
https://psnet.ahrq.gov/issue/ashp-iv-adult-continuous-infusions
Miscalculations of intravenous infusion concentrations can result in patient harm. Representing the first
phase of a standards deve…