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psnet.ahrq.gov/node/44867/psn-pdf
March 23, 2016 - Understanding why quality initiatives succeed or fail: a
sociotechnical systems perspective.
March 23, 2016
Wiegmann DA. Understanding Why Quality Initiatives Succeed or Fail: A Sociotechnical Systems
Perspective. Ann Surg. 2016;263(1):9-11. doi:10.1097/SLA.0000000000001333.
https://psnet.ahrq.gov/issue/understand…
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psnet.ahrq.gov/node/72501/psn-pdf
November 25, 2020 - Use of an audit with feedback implementation strategy to
promote medication error reporting by nurses.
November 25, 2020
Hutchinson A, Brotto V, Chapman A, et al. Use of an audit with feedback implementation strategy to
promote medication error reporting by nurses. J Clin Nurs. 2020;29(21-22):4180-4193.
doi:10.111…
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psnet.ahrq.gov/node/47431/psn-pdf
September 26, 2018 - Partnering with pediatric patients and families in high
reliability to identify and reduce preventable safety
events.
September 26, 2018
Kirby J, Cannon C, Darrah L, et al. Patient Exp J. 2018;5:76-90.
https://psnet.ahrq.gov/issue/partnering-pediatric-patients-and-families-high-reliability-identify-and-reduce-
pr…
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psnet.ahrq.gov/node/48180/psn-pdf
August 21, 2019 - Burnout and Resilience and Quality and Safety Programs
in Obstetrics and Gynecology.
August 21, 2019
Main EK, Fowler JM, Gabbe SG, eds. Clin Obstet Gynecol. 2019;62:vii-xii,403-626.
https://psnet.ahrq.gov/issue/burnout-and-resilience-and-quality-and-safety-programs-obstetrics-and-
gynecology
Obstetrics is a high-…
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psnet.ahrq.gov/node/43907/psn-pdf
April 27, 2015 - Association of hospital participation in a surgical
outcomes monitoring program with inpatient
complications and mortality.
April 27, 2015
Etzioni DA, Wasif N, Dueck AC, et al. Association of hospital participation in a surgical outcomes
monitoring program with inpatient complications and mortality. JAMA. 2015;313…
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psnet.ahrq.gov/node/46825/psn-pdf
June 19, 2018 - Diagnostic performance dashboards: tracking diagnostic
errors using big data.
June 19, 2018
Mane KK, Rubenstein KB, Nassery N, et al. Diagnostic performance dashboards: tracking diagnostic errors
using big data. BMJ Qual Saf. 2018;27(7):567-570. doi:10.1136/bmjqs-2018-007945.
https://psnet.ahrq.gov/issue/diagnosti…
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psnet.ahrq.gov/node/46227/psn-pdf
October 30, 2017 - Patient engagement with surgical site infection
prevention: an expert panel perspective.
October 30, 2017
Tartari E, Weterings V, Gastmeier P, et al. Patient engagement with surgical site infection prevention: an
expert panel perspective. Antimicrob Resist Infect Control. 2017;6:45. doi:10.1186/s13756-017-0202-3.
…
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psnet.ahrq.gov/node/47802/psn-pdf
March 04, 2019 - The path to diagnostic excellence includes feedback to
calibrate how clinicians think.
March 4, 2019
Meyer AND, Singh H. The Path to Diagnostic Excellence Includes Feedback to Calibrate How Clinicians
Think. JAMA. 2019;321(8):737-738. doi:10.1001/jama.2019.0113.
https://psnet.ahrq.gov/issue/path-diagnostic-excelle…
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psnet.ahrq.gov/node/48034/psn-pdf
May 22, 2019 - Chasing zero harm in radiation oncology: using pre-
treatment peer review.
May 22, 2019
Vijayakumar S, Duggar WN, Packianathan S, et al. Chasing Zero Harm in Radiation Oncology: Using Pre-
treatment Peer Review. Front Oncol. 2019;9:302. doi:10.3389/fonc.2019.00302.
https://psnet.ahrq.gov/issue/chasing-zero-harm-ra…
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psnet.ahrq.gov/node/853074/psn-pdf
February 06, 2024 - Patient Experience, Patient Safety, and Provider Well-
Being: Associations and Paths for Quality Improvement.
February 6, 2024
Rockville, MD: Agency for Healthcare Research and Quality; January 2024. AHRQ Publication no.
24-0030.
https://psnet.ahrq.gov/issue/patient-experience-patient-safety-and-provider-well…
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psnet.ahrq.gov/node/43283/psn-pdf
June 25, 2014 - Development, implementation, and dissemination of the I-
PASS Handoff Curriculum: a multisite educational
intervention to improve patient handoffs.
June 25, 2014
Starmer AJ, O'Toole JK, Rosenbluth G, et al. Development, implementation, and dissemination of the I-
PASS handoff curriculum: A multisite educational in…
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psnet.ahrq.gov/node/48070/psn-pdf
July 17, 2019 - Controversies in diagnosis: contemporary debates in the
diagnostic safety literature.
July 17, 2019
Bergl PA, Wijesekera TP, Nassery N, et al. Controversies in diagnosis: contemporary debates in the
diagnostic safety literature. Diagnosis (Berl). 2020;7(1):3-9. doi:10.1515/dx-2019-0016.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/45499/psn-pdf
May 03, 2017 - Patient safety and interprofessional education: a report of
key issues from two interprofessional workshops.
May 3, 2017
Anderson ES, Gray R, Price K. Patient safety and interprofessional education: A report of key issues from
two interprofessional workshops. J Interprof Care. 2017;31(2):154-163.
doi:10.1080/13561…
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psnet.ahrq.gov/node/60060/psn-pdf
March 18, 2020 - The benefits and burdens of working with patient safety
organizations under the Patient Safety and Quality
Improvement Act of 2005.
March 18, 2020
Dwyer PE, Watts CD. The benefits and burdens of working with patient safety organizations under the
Patient Safety and Quality Improvement Act of 2005. J Health Life Sc…
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psnet.ahrq.gov/node/74856/psn-pdf
February 23, 2022 - The secondary use of data to support medication safety
in the hospital setting: a systematic review and narrative
synthesis.
February 23, 2022
Chaudhry NT, Franklin BD, Mohammed S, et al. The secondary use of data to support medication safety in
the hospital setting: a systematic review and narrative synthesis. Ph…
-
psnet.ahrq.gov/node/73532/psn-pdf
July 28, 2021 - The standardisation of handoffs in a large academic
paediatric emergency department using I-PASS.
July 28, 2021
Chladek MS, Doughty C, Patel B, et al. The Standardisation of handoffs in a large academic paediatric
emergency department using I-PASS. BMJ Open Qual. 2021;10(3):e001254. doi:10.1136/bmjoq-2020-
001254.…
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psnet.ahrq.gov/node/47002/psn-pdf
April 25, 2018 - Making Health Care Safer in Ambulatory Care Settings
and Long Term Care Facilities (R18).
April 25, 2018
Rockville, MD: Agency for Healthcare Research and Quality; April 10, 2018. PA-18-750.
https://psnet.ahrq.gov/issue/making-health-care-safer-ambulatory-care-settings-and-long-term-care-
facilities-r18
Research …
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psnet.ahrq.gov/node/864371/psn-pdf
March 13, 2024 - The ritualisation of the surgical safety checklist and its
decoupling from patient safety goals.
March 13, 2024
Facey M, Baxter NN, Hammond Mobilio M, et al. The ritualisation of the surgical safety checklist and its
decoupling from patient safety goals. Sociol Health Illn. 2024;46(6):1100-1118. doi:10.1111/1467-
…
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psnet.ahrq.gov/node/60823/psn-pdf
August 19, 2020 - Disaster ergonomics: human factors in COVID-19
pandemic emergency management.
August 19, 2020
Sasangohar F, Moats J, Mehta R, et al. Disaster ergonomics: human factors in COVID-19 pandemic
emergency management. Hum Factors. 2020;62(7):1061-1068. doi:10.1177/0018720820939428.
https://psnet.ahrq.gov/issue/disaster-e…
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psnet.ahrq.gov/node/34803/psn-pdf
January 05, 2017 - Systematic root cause analysis of adverse drug events in
a tertiary referral hospital.
January 5, 2017
Rex JH, Turnbull JE, Allen SJ, et al. Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary
Referral Hospital. Jt Comm J Qual Improv. 2016;26(10). doi:10.1016/s1070-3241(00)26048-3.
https://psnet.ah…