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psnet.ahrq.gov/node/43329/psn-pdf
July 09, 2014 - Facilitating a safe transition from the pediatric emergency
department to home with a post-discharge phone call: a
quality-improvement initiative to improve patient safety.
July 9, 2014
Bucaro PJ, Black E. Facilitating a safe transition from the pediatric emergency department to home with a
post-discharge phone ca…
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psnet.ahrq.gov/node/42439/psn-pdf
November 23, 2016 - Guide to Patient and Family Engagement in Hospital
Quality and Safety.
November 23, 2016
Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
https://psnet.ahrq.gov/issue/guide-patient-and-family-engagement-hospital-quality-and-safety
Studies have shown that a surprisingly large proportion of hosp…
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psnet.ahrq.gov/node/45953/psn-pdf
July 22, 2020 - Root Cause Analysis in Health Care: A Joint Commission
Guide to Analysis and Corrective Action of Sentinel and
Adverse Events.
July 22, 2020
Oakbrook Terrace, IL: Joint Commission Resources; 2020. ISBN: 9781635851618.
https://psnet.ahrq.gov/issue/root-cause-analysis-health-care-joint-commission-guide-analysis-and-…
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psnet.ahrq.gov/node/46163/psn-pdf
December 06, 2017 - Defining the critical role of nurses in diagnostic error
prevention: a conceptual framework and a call to action.
December 6, 2017
Gleason KT, Davidson PM, Tanner EK, et al. Defining the critical role of nurses in diagnostic error
prevention: a conceptual framework and a call to action. Diagnosis (Berl). 2017;4(4):…
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psnet.ahrq.gov/node/865872/psn-pdf
May 15, 2024 - Speaking up and taking action: psychological safety and
joint problem-solving orientation in safety improvement.
May 15, 2024
Bahadurzada H, Kerrissey M, Edmondson AC. Speaking up and taking action: psychological safety and
joint problem-solving orientation in safety improvement. Healthcare (Basel). 2024;12(8):812.…
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psnet.ahrq.gov/node/45861/psn-pdf
April 05, 2017 - Assessing content validity and user perspectives on the
Team Check-up Tool: expert survey and user focus
groups.
April 5, 2017
Marsteller JA, Hsu Y-J, Chan KS, et al. Assessing content validity and user perspectives on the Team
Check-up Tool: expert survey and user focus groups. BMJ Qual Saf. 2017;26(4):288-295.
…
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psnet.ahrq.gov/node/74757/psn-pdf
February 09, 2022 - Characteristics of disease-specific and generic diagnostic
pitfalls: a qualitative study.
February 9, 2022
Schiff GD, Volodarskaya M, Ruan E, et al. Characteristics of disease-specific and generic diagnostic
pitfalls: a qualitative study. JAMA Netw Open. 2022;5(1):e2144531.
doi:10.1001/jamanetworkopen.2021.44531.
…
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psnet.ahrq.gov/node/45967/psn-pdf
July 05, 2017 - Root-cause analysis: swatting at mosquitoes versus
draining the swamp.
July 5, 2017
Trbovich PL, Shojania KG. Root-cause analysis: swatting at mosquitoes versus draining the swamp. BMJ
Qual Saf. 2017;26(5):350-353. doi:10.1136/bmjqs-2016-006229.
https://psnet.ahrq.gov/issue/root-cause-analysis-swatting-mosquitoes-…
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psnet.ahrq.gov/node/854825/psn-pdf
October 25, 2023 - Exploring the "Black Box" of recommendation generation
in local health care incident investigations: a scoping
review.
October 25, 2023
Lea W, Lawton R, Vincent CA, et al. Exploring the "Black Box" of recommendation generation in local
health care incident investigations: a scoping review. J Patient Saf. 2023;19(8…
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psnet.ahrq.gov/node/41141/psn-pdf
February 15, 2013 - An examination of opportunities for the active patient in
improving patient safety.
February 15, 2013
Davis R, Sevdalis N, Jacklin R, et al. An examination of opportunities for the active patient in improving
patient safety. J Patient Saf. 2012;8(1):36-43. doi:10.1097/PTS.0b013e31823cba94.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/47629/psn-pdf
July 11, 2019 - How not to waste a crisis: a qualitative study of problem
definition and its consequences in three hospitals.
July 11, 2019
Martin G, Ozieranski P, Leslie M, et al. How not to waste a crisis: a qualitative study of problem definition
and its consequences in three hospitals. J Health Serv Res Policy. 2019;24(3):145-…
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psnet.ahrq.gov/node/39512/psn-pdf
June 11, 2010 - An intervention to decrease patient identification band
errors in a children's hospital.
June 11, 2010
Hain PD, Joers B, Rush M, et al. An intervention to decrease patient identification band errors in a
children's hospital. Qual Saf Health Care. 2010;19(3):244-7. doi:10.1136/qshc.2008.030288.
https://psnet.ahrq.g…
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psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
January 01, 2022 - Spotlight
Spotlight
A Case of Mistaken Capacity: Why a
Thorough Psychosocial History Can
Improve Care
Source and Credits
• This presentation is based on the March 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Katrina Pasao, MD…
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psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
August 31, 2020 - In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE
August 31, 2020
Also Read the Essay
Citation Text:
In Conversation With.. Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE. PSNet [internet]. 2020.In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA-BC-…
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psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
January 29, 2021 - Angiography six hours after event revealed restoration of flow in the radial artery and improved perfusion
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psnet.ahrq.gov/node/49759/psn-pdf
May 01, 2016 - She slowly improved with antibiotics and
supportive care and was ultimately discharged to a nursing
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psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
March 27, 2024 - These authors found that reformatting axial CT scans to include coronal and sagittal images improved
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - The use of diagnostic imaging has increased significantly over the last 20 years, driven largely by improved
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psnet.ahrq.gov/web-mm/deadly-duo
April 28, 2021 - upper gastrointestinal bleeding, particularly in patients concomitantly taking NSAIDS.( 26-29 ) With improved
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Within the next few hours, the patient’s condition improved.