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psnet.ahrq.gov/node/849136/psn-pdf
May 17, 2023 - Using morbidity and mortality conferences to drive
quality improvement and reduce errors.
May 17, 2023
Lai B, Horn J, Wilkinson J, et al. Fam Pract Manag. 2023;30(2):13-17.
https://psnet.ahrq.gov/issue/using-morbidity-and-mortality-conferences-drive-quality-improvement-and-
reduce-errors
Morbidity and mortality (…
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psnet.ahrq.gov/node/37178/psn-pdf
October 06, 2011 - Randomized trial to improve prescribing safety in
ambulatory elderly patients.
October 6, 2011
Raebel MA, Charles J, Dugan J, et al. Randomized trial to improve prescribing safety in ambulatory elderly
patients. J Am Geriatr Soc. 2007;55(7):977-85.
https://psnet.ahrq.gov/issue/randomized-trial-improve-prescribing-…
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psnet.ahrq.gov/node/46907/psn-pdf
April 11, 2018 - To combat physician burnout and improve care, fix the
electronic health record.
April 11, 2018
Wachter R, Goldsmith J. Harv Bus Rev. March 30, 2018.
https://psnet.ahrq.gov/issue/combat-physician-burnout-and-improve-care-fix-electronic-health-record
Increased workload associated with electronic health record (EHR) …
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psnet.ahrq.gov/node/867529/psn-pdf
January 15, 2025 - “I had no idea this happened”: electronic feedback on
clinical reasoning for hospitalists.
January 15, 2025
Kotwal S, Udayappan KM, Kutheala N, et al. “I had no idea this happened”: electronic feedback on clinical
reasoning for hospitalists. J Gen Intern Med. 2024;39(16):3271-3277. doi:10.1007/s11606-024-09058-1.
…
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psnet.ahrq.gov/node/837201/psn-pdf
May 25, 2022 - Near miss research in the healthcare system: a scoping
review.
May 25, 2022
Feng T-ting, Zhang X, Tan L-ling, et al. Near miss research in the healthcare system: a scoping review. J
Nurs Adm. 2022;52(3):160-166. doi:10.1097/nna.0000000000001124.
https://psnet.ahrq.gov/issue/near-miss-research-healthcare-system-sco…
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psnet.ahrq.gov/node/44455/psn-pdf
September 02, 2015 - Finding antecedents of psychological safety: a step
toward quality improvement.
September 2, 2015
Aranzamendez G, James D, Toms R. Finding Antecedents of Psychological Safety: A Step Toward Quality
Improvement. Nurs Forum. 2015;50(3):171-178. doi:10.1111/nuf.12084.
https://psnet.ahrq.gov/issue/finding-antecedents-…
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psnet.ahrq.gov/node/45024/psn-pdf
December 19, 2017 - Leveraging a redesigned morbidity and mortality
conference that incorporates the clinical and educational
missions of improving quality and patient safety.
December 19, 2017
Tad-Y DB, Pierce RG, Pell JM, et al. Leveraging a Redesigned Morbidity and Mortality Conference That
Incorporates the Clinical and Educationa…
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psnet.ahrq.gov/node/34700/psn-pdf
January 04, 2017 - Reducing adverse drug events: lessons from a
breakthrough series collaborative.
January 4, 2017
Leape L, Kabcenell AI, Gandhi TK, et al. Reducing adverse drug events: lessons from a breakthrough
series collaborative. Jt Comm J Qual Improv. 2000;26(6):321-31.
https://psnet.ahrq.gov/issue/reducing-adverse-drug-event…
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psnet.ahrq.gov/node/74699/psn-pdf
January 26, 2022 - Indication alerts to improve problem list documentation.
January 26, 2022
Grauer A, Kneifati-Hayek J, Reuland B, et al. Indication alerts to improve problem list documentation. J Am
Med Inform Assoc. 2022;29(5):909-917. doi:10.1093/jamia/ocab285.
https://psnet.ahrq.gov/issue/indication-alerts-improve-problem-list-d…
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psnet.ahrq.gov/node/35909/psn-pdf
October 07, 2008 - Committed to Safety: Ten Case Studies on Reducing
Harm to Patients.
October 7, 2008
McCarthy D, Blumenthal D. New York, NY: Commonwealth Fund; 2006.
https://psnet.ahrq.gov/issue/committed-safety-ten-case-studies-reducing-harm-patients
This report presents ten case studies to illustrate interventions that address p…
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psnet.ahrq.gov/node/867182/psn-pdf
November 20, 2024 - Combining multiple large language models improves
diagnostic accuracy.
November 20, 2024
Barabucci G, Shia V, Chu ES, et al. Combining multiple large language models improves diagnostic
accuracy. NEJM AI. 2024;1(11):AIcs2400502. doi:10.1056/aics2400502.
https://psnet.ahrq.gov/issue/combining-multiple-large-languag…
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psnet.ahrq.gov/node/44891/psn-pdf
July 03, 2016 - Characteristics of morbidity and mortality conferences
associated with the implementation of patient safety
improvement initiatives, an observational study.
July 3, 2016
François P, Prate F, Vidal-Trecan G, et al. Characteristics of morbidity and mortality conferences
associated with the implementation of patient …
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psnet.ahrq.gov/node/43886/psn-pdf
July 13, 2016 - The Armstrong Institute Resident/Fellow Scholars: a
multispecialty curriculum to train future leaders in patient
safety and quality improvement.
July 13, 2016
Rinke ML, Mock CK, Persing NM, et al. The Armstrong Institute Resident/Fellow Scholars: A Multispecialty
Curriculum to Train Future Leaders in Patient Safet…
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psnet.ahrq.gov/node/33559/psn-pdf
December 15, 2024 - Medication Reconciliation
December 15, 2024
Medication Reconciliation. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/medication-reconciliation
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safet…
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psnet.ahrq.gov/issue/making-healthcare-safe-story-patient-safety-movement
January 20, 2021 - Book/Report
Making Healthcare Safe: The Story of the Patient Safety Movement.
Citation Text:
Making Healthcare Safe: The Story of the Patient Safety Movement. Leape LL. Cham, Switzerland: Springer Nature; 2021. ISBN: 9783030711252.
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psnet.ahrq.gov/issue/root-cause-analysis-health-care-joint-commission-guide-analysis-and-corrective-action
November 27, 2018 - Book/Report
Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events.
Citation Text:
Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events. Oakbroo…
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psnet.ahrq.gov/issue/providing-safe-high-quality-maternity-care-rural-us-hospitals-ihi-innovation-report
November 02, 2016 - Book/Report
Providing Safe, High-Quality Maternity Care in Rural US Hospitals. IHI Innovation Report.
Citation Text:
Providing Safe, High-Quality Maternity Care in Rural US Hospitals. IHI Innovation Report. Laderman M, Renton M. Boston, MA: Institute for Healthcare Improvement; 2020.
…
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psnet.ahrq.gov/issue/keeping-commitment-progress-report-four-early-leaders-patient-safety-improvement
October 07, 2008 - Book/Report
Keeping the Commitment: A Progress Report on Four Early Leaders in Patient Safety Improvement.
Citation Text:
Keeping the Commitment: A Progress Report on Four Early Leaders in Patient Safety Improvement. McCarthy D, Klein S. New York, NY: The Commonwealth Fund; March 15,…
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psnet.ahrq.gov/issue/improving-diagnostic-quality-safetyreducing-diagnostic-error-measurement-considerations
November 20, 2019 - Book/Report
Improving Diagnostic Quality & Safety/Reducing Diagnostic Error: Measurement Considerations.
Citation Text:
Improving Diagnostic Quality & Safety/Reducing Diagnostic Error: Measurement Considerations. Washington DC; National Quality Forum: October 28, 2019.
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psnet.ahrq.gov/issue/advancing-safety-acute-pain-management
January 08, 2020 - Book/Report
Advancing the Safety of Acute Pain Management.
Citation Text:
Advancing the Safety of Acute Pain Management. Boston, MA: Institute for Healthcare Improvement; 2019.
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