-
psnet.ahrq.gov/node/33568/psn-pdf
June 15, 2024 - Root Cause Analysis
June 15, 2024
Root Cause Analysis. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/root-cause-analysis
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 safety field. Last reviewed…
-
psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
August 22, 2014 - In Conversation With… Urmimala Sarkar, MD, MPH
August 1, 2014
Also Read an Essay
Citation Text:
In Conversation With… Urmimala Sarkar, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
-
psnet.ahrq.gov/node/33737/psn-pdf
September 01, 2012 - Preparing for Health Reform: The Federal Government
and the Nursing Workforce
September 1, 2012
Buerhaus P. Preparing for Health Reform: The Federal Government and the Nursing Workforce. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
Per…
-
psnet.ahrq.gov/node/50887/psn-pdf
February 12, 2020 - Lessons learned from a systems approach to engaging
patients and families in patient safety transformation.
February 12, 2020
Hatlie MJ, Nahum A, Leonard R, et al. Lessons Learned from a Systems Approach to Engaging Patients
and Families in Patient Safety Transformation. Jt Comm J Qual Patient Saf. 2020;46(3):158-1…
-
psnet.ahrq.gov/node/837848/psn-pdf
August 17, 2022 - Health care quality and safety in a correctional system:
creating goals and performance measures for
improvement.
August 17, 2022
Neely J, Sampath R, Kirkbride G, et al. Health care quality and safety in a correctional system: creating
goals and performance measures for improvement. J Correct Health Care. 2022;28(…
-
psnet.ahrq.gov/node/44314/psn-pdf
November 06, 2015 - Unintentional discontinuation of chronic medications for
seniors in nursing homes: evaluation of a national
medication reconciliation accreditation requirement using
a population-based cohort study.
November 6, 2015
Stall NM, Fischer HD, Wu F, et al. Unintentional Discontinuation of Chronic Medications for Seniors…
-
psnet.ahrq.gov/node/854835/psn-pdf
October 25, 2023 - Improving patient safety by shifting power from health
professionals to patients.
October 25, 2023
BMJ. 2023(383):2219, 2278, 2319, 2331.
https://psnet.ahrq.gov/issue/improving-patient-safety-shifting-power-health-professionals-patients
This compendium of editorials and opinion pieces discuss “Martha’s Rule,” a ne…
-
psnet.ahrq.gov/node/844989/psn-pdf
February 22, 2023 - Defining and enhancing collaboration between
community pharmacists and primary care providers to
improve medication safety.
February 22, 2023
White A, Fulda KG, Blythe R, et al. Defining and enhancing collaboration between community pharmacists
and primary care providers to improve medication safety. Expert Opin D…
-
psnet.ahrq.gov/node/45772/psn-pdf
January 11, 2017 - Technical Series on Safer Primary Care.
January 11, 2017
Geneva, Switzerland: World Health Organization; 2016.
https://psnet.ahrq.gov/issue/technical-series-safer-primary-care
Much of patient safety research has focused on the hospital setting, but a majority of health care is
delivered in the ambulatory setting. …
-
psnet.ahrq.gov/node/41643/psn-pdf
September 05, 2012 - A Randomized Field Study of a Leadership WalkRounds-
Based Intervention.
September 5, 2012
Tucker AL, Singer SJ. Cambridge, MA: Harvard Business School; June 25, 2012. HBS Working Paper No.
12-113.
https://psnet.ahrq.gov/issue/randomized-field-study-leadership-walkrounds-based-intervention
Leadership WalkRounds h…
-
psnet.ahrq.gov/node/45943/psn-pdf
March 15, 2017 - Identifying and reducing complications after emergency
room discharge.
March 15, 2017
Hofmann PB, Bagian JP. Patient Saf Qual Healthc. February 20, 2017.
https://psnet.ahrq.gov/issue/identifying-and-reducing-complications-after-emergency-room-discharge
Emergency departments are complex environments that harbor fac…
-
psnet.ahrq.gov/node/45570/psn-pdf
December 07, 2016 - Getting the Board on Board: What Your Board Needs to
Know About Quality and Safety, Third Edition.
December 7, 2016
Oak Brook, IL; Joint Commission; 2016. ISBN: 9781599409412.
https://psnet.ahrq.gov/issue/getting-board-board-what-your-board-needs-know-about-quality-and-safety-
third-edition
Engaging hospital lead…
-
psnet.ahrq.gov/node/38157/psn-pdf
October 22, 2008 - Contributing factors identified by hospital incident report
narratives.
October 22, 2008
Nuckols TK, Bell DS, Paddock SM, et al. Contributing factors identified by hospital incident report
narratives. Qual Saf Health Care. 2008;17(5):368-72. doi:10.1136/qshc.2007.023721.
https://psnet.ahrq.gov/issue/contributing-f…
-
psnet.ahrq.gov/node/45563/psn-pdf
October 19, 2016 - Using a change model to reduce the risk of surgical site
infection.
October 19, 2016
Burden M. Using a change model to reduce the risk of surgical site infection. Br J Nurs. 2016;25(17):949-
955.
https://psnet.ahrq.gov/issue/using-change-model-reduce-risk-surgical-site-infection
Surgical site infections can resul…
-
psnet.ahrq.gov/node/60235/psn-pdf
April 15, 2020 - Independent Mortality Review of Cardiac Surgery at St
George’s University Hospitals NHS Foundation Trust.
April 15, 2020
NHS Improvement. Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals
NHS Foundation Trust. NHS England. March 2020.
https://psnet.ahrq.gov/issue/independent-morta…
-
psnet.ahrq.gov/node/35218/psn-pdf
August 07, 2018 - Building a Memory: Preventing Harm, Reducing Risks and
Improving Patient Safety.
August 7, 2018
Scobie S, Thomson R. London, UK : National Patient Safety Agency; 2005.
https://psnet.ahrq.gov/issue/building-memory-preventing-harm-reducing-risks-and-improving-patient-safety
Created in 2001 to institute changes in he…
-
psnet.ahrq.gov/node/74758/psn-pdf
February 09, 2022 - Emotional harm in the radiology department: analysis of
an underrecognized preventable error.
February 9, 2022
Siewert B, Swedeen S, Brook OR, et al. Emotional harm in the radiology department: analysis of an
underrecognized preventable error. Radiology. 2022;302(3):613-619. doi:10.1148/radiol.2021211846.
https://…
-
psnet.ahrq.gov/node/46579/psn-pdf
April 11, 2018 - Electronic medicine can send you test results quickly. But
what if they're scary?
April 11, 2018
Boodman SG. Washington Post. March 26, 2018.
https://psnet.ahrq.gov/issue/electronic-medicine-can-send-you-test-results-quickly-what-if-theyre-scary
Although providing patients with access to physician notes and test r…
-
psnet.ahrq.gov/node/46844/psn-pdf
March 07, 2018 - Learning collaboratives: insights and a new taxonomy
from AHRQ's two decades of experience.
March 7, 2018
Nix M, McNamara P, Genevro J, et al. Learning Collaboratives: Insights And A New Taxonomy From
AHRQ's Two Decades Of Experience. Health Aff (Millwood). 2018;37(2):205-212.
doi:10.1377/hlthaff.2017.1144.
https…
-
psnet.ahrq.gov/node/73065/psn-pdf
March 24, 2021 - Implementing the clinical occurrence reporting and
learning system: a double-loop learning incident
reporting system in long-term care.
March 24, 2021
Goh HS, Tan V, Chang J, et al. Implementing the clinical occurrence reporting and learning system: a
double-loop learning incident reporting system in long-term car…