-
psnet.ahrq.gov/node/47167/psn-pdf
May 30, 2018 - AHRQ Health Information Technology Division's 2017
Annual Report.
May 30, 2018
Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0028-
EF.
https://psnet.ahrq.gov/issue/ahrq-health-information-technology-divisions-2017-annual-report
Health care has worked to enhance use…
-
psnet.ahrq.gov/node/44821/psn-pdf
December 05, 2022 - Action Planning Tool for the AHRQ Surveys on Patient
Safety Culture.
December 5, 2022
Yount N, Edelman S, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; November
2022. AHRQ Publication No. 23-0011.
https://psnet.ahrq.gov/issue/action-planning-tool-ahrq-surveys-patient-safety-culture
Im…
-
psnet.ahrq.gov/node/44597/psn-pdf
October 28, 2015 - Smarter clinical checklists: how to minimize checklist
fatigue and maximize clinician performance.
October 28, 2015
Grigg EB. Smarter Clinical Checklists: How to Minimize Checklist Fatigue and Maximize Clinician
Performance. Anesth Analg. 2015;121(2):570-3. doi:10.1213/ANE.0000000000000352.
https://psnet.ahrq.gov/…
-
psnet.ahrq.gov/node/47200/psn-pdf
August 20, 2018 - Creating a comprehensive, unit-based approach to
detecting and preventing harm in the neonatal intensive
care unit.
August 20, 2018
Sedlock EW, Ottosen M, Nether K, et al. J Patient Saf Risk Manag. 2018;23:167–175.
https://psnet.ahrq.gov/issue/creating-comprehensive-unit-based-approach-detecting-and-preventing-har…
-
psnet.ahrq.gov/node/44651/psn-pdf
December 09, 2015 - Measurement of diagnostic errors is a key first step to
their reduction.
December 9, 2015
Singh H. National Quality Measures Expert Commentaries. November 23, 2015.
https://psnet.ahrq.gov/issue/measurement-diagnostic-errors-key-first-step-their-reduction
Recently, diagnostic error has garnered much discussion and …
-
psnet.ahrq.gov/node/45812/psn-pdf
June 22, 2017 - A primer on PDSA: executing plan–do–study–act cycles
in practice, not just in name.
June 22, 2017
Leis JA, Shojania KG. A primer on PDSA: executing plan-do-study-act cycles in practice, not just in name.
BMJ Qual Saf. 2017;26(7):572-577. doi:10.1136/bmjqs-2016-006245.
https://psnet.ahrq.gov/issue/primer-pdsa-execu…
-
psnet.ahrq.gov/node/46938/psn-pdf
April 25, 2018 - Diagnostic reasoning and cognitive biases of nurse
practitioners.
April 25, 2018
Lawson TN. Diagnostic Reasoning and Cognitive Biases of Nurse Practitioners. J Nurs Educ.
2018;57(4):203-208. doi:10.3928/01484834-20180322-03.
https://psnet.ahrq.gov/issue/diagnostic-reasoning-and-cognitive-biases-nurse-practitioners…
-
psnet.ahrq.gov/node/44911/psn-pdf
February 17, 2016 - Improving doctor–patient communication in a digital
world.
February 17, 2016
Lakshmanan I. The Diane Rehm Show. February 9, 2016.
https://psnet.ahrq.gov/issue/improving-doctor-patient-communication-digital-world
Digital technologies represent both promise and risks for communication in health care. This radio inte…
-
psnet.ahrq.gov/node/45034/psn-pdf
February 25, 2019 - Future directions for diagnostic decision support.
February 25, 2019
Carr S. ImproveDx. April 2016;3:1-3.
https://psnet.ahrq.gov/issue/future-directions-diagnostic-decision-support
Clinical decision support systems are tools being used to augment clinical reasoning and diagnostic
accuracy. This newsletter article …
-
psnet.ahrq.gov/node/47377/psn-pdf
February 20, 2019 - Every patient should be enabled to stop the line.
February 20, 2019
Bell SK, Martinez W. Every patient should be enabled to stop the line. BMJ Qual Saf. 2019;28(3):172-176.
doi:10.1136/bmjqs-2018-008714.
https://psnet.ahrq.gov/issue/every-patient-should-be-enabled-stop-line
The Toyota manufacturing model "stop the…
-
psnet.ahrq.gov/node/74710/psn-pdf
January 26, 2022 - The evolution of the Anesthesia Patient Safety Movement
in America: lessons learned and considerations to
promote further improvement in patient safety.
January 26, 2022
Warner MA, Warner ME. The evolution of the Anesthesia Patient Safety Movement in America: lessons
learned and considerations to promote further i…
-
psnet.ahrq.gov/node/836758/psn-pdf
March 16, 2022 - Internet of things in healthcare for patient safety: an
empirical study.
March 16, 2022
Yesmin T, Carter MW, Gladman AS. Internet of things in healthcare for patient safety: an empirical study.
BMC Health Serv Res. 2022;22(1):278. doi:10.1186/s12913-022-07620-3.
https://psnet.ahrq.gov/issue/internet-things-healthc…
-
psnet.ahrq.gov/node/48120/psn-pdf
July 17, 2019 - 2018 John M. Eisenberg Patient Safety and Quality
Awards.
July 17, 2019
Jt Comm J Qual Patient Saf. 2019;45(7):461-486.
https://psnet.ahrq.gov/issue/2018-john-m-eisenberg-patient-safety-and-quality-awards
The Eisenberg Award honors individuals and organizations who have made important contributions to
patient saf…
-
psnet.ahrq.gov/node/840167/psn-pdf
November 16, 2022 - 'Reading the Signals' : Maternity and Neonatal Services in
East Kent – the Report of the Independent Investigation.
November 16, 2022
Kirkup B. Department of Health and Social Care. London, England: Crown Copyright; 2022. ISBN:
9781528636759.
https://psnet.ahrq.gov/issue/reading-signals-maternity-and-neonata…
-
psnet.ahrq.gov/node/44868/psn-pdf
June 17, 2016 - Patient safety and the problem of many hands.
June 17, 2016
Dixon-Woods M, Pronovost P. Patient safety and the problem of many hands. BMJ Qual Saf.
2016;25(7):485-488. doi:10.1136/bmjqs-2016-005232.
https://psnet.ahrq.gov/issue/patient-safety-and-problem-many-hands
Although individual and organizational accountabi…
-
psnet.ahrq.gov/node/861769/psn-pdf
January 31, 2024 - Psychological safety and hierarchy in operating room
debriefing: reflexive thematic analysis.
January 31, 2024
McElroy C, Skegg E, Mudgway M, et al. Psychological safety and hierarchy in operating room debriefing:
reflexive thematic analysis. J Surg Res. 2023;295:567-573. doi:10.1016/j.jss.2023.11.054.
https://psn…
-
psnet.ahrq.gov/node/44465/psn-pdf
November 20, 2015 - Why even good physicians do not wash their hands.
November 20, 2015
Redelmeier DA, Shafir E. Why even good physicians do not wash their hands. BMJ Qual Saf.
2015;24(12):744-7. doi:10.1136/bmjqs-2015-004319.
https://psnet.ahrq.gov/issue/why-even-good-physicians-do-not-wash-their-hands
Insufficient hand hygiene comp…
-
psnet.ahrq.gov/node/47057/psn-pdf
July 14, 2018 - A framework for operationalizing risk: a practical
approach to patient safety.
July 14, 2018
Mathews SC, Sutcliffe K, Garrett MR, et al. A framework for operationalizing risk: A practical approach to
patient safety. J Healthc Risk Manag. 2018;38(1):38-46. doi:10.1002/jhrm.21317.
https://psnet.ahrq.gov/issue/frame…
-
psnet.ahrq.gov/node/44125/psn-pdf
May 28, 2015 - AHRQ focuses on ambulatory patient safety.
May 28, 2015
Ricciardi R. AHRQ Focuses on Ambulatory Patient Safety. J Nurs Care Qual. 2015;30(3):193-6.
doi:10.1097/NCQ.0000000000000124.
https://psnet.ahrq.gov/issue/ahrq-focuses-ambulatory-patient-safety
AHRQ has generated funding and educational opportunities toward u…
-
psnet.ahrq.gov/node/46387/psn-pdf
September 06, 2017 - A multicomponent fall prevention strategy reduces falls at
an academic medical center.
September 6, 2017
France D, Slayton J, Moore S, et al. A Multicomponent Fall Prevention Strategy Reduces Falls at an
Academic Medical Center. The Joint Commission Journal on Quality and Patient Safety. 2017;43(9).
doi:10.1016/j.…