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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…
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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…
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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…
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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://…
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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…
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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…
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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…
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psnet.ahrq.gov/node/47305/psn-pdf
March 19, 2019 - Effect of genetic diagnosis on patients with previously
undiagnosed disease.
March 19, 2019
Splinter K, Adams DR, Bacino CA, et al. Effect of Genetic Diagnosis on Patients with Previously
Undiagnosed Disease. New Engl J Med. 2018;379(22):2131-2139. doi:10.1056/NEJMoa1714458.
https://psnet.ahrq.gov/issue/effect-gen…
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psnet.ahrq.gov/node/47568/psn-pdf
March 06, 2019 - Trends in anesthesia-related liability and lessons learned.
March 6, 2019
Mora JC, Kaye AD, Romankowski ML, et al. Trends in Anesthesia-Related Liability and Lessons Learned.
Adv Anesth. 2018;36(1):231-249. doi:10.1016/j.aan.2018.07.009.
https://psnet.ahrq.gov/issue/trends-anesthesia-related-liability-and-lessons-l…
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psnet.ahrq.gov/node/851361/psn-pdf
July 12, 2023 - Types and effects of feedback for emergency ambulance
staff: a systematic mixed studies review and meta-
analysis.
July 12, 2023
Wilson C, Janes G, Lawton R, et al. Types and effects of feedback for emergency ambulance staff: a
systematic mixed studies review and meta-analysis. BMJ Qual Saf. 2023;32(10):573-588.
…
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psnet.ahrq.gov/node/73107/psn-pdf
April 07, 2021 - Crisis checklists in emergency medicine: another step
forward for cognitive aids.
April 7, 2021
Chen Y-YK, Arriaga AF. Crisis checklists in emergency medicine: another step forward for cognitive aids.
BMJ Qual Saf. 2021;30(9):689-693. doi:10.1136/bmjqs-2021-013203.
https://psnet.ahrq.gov/issue/crisis-checklists-em…
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psnet.ahrq.gov/node/865704/psn-pdf
May 01, 2024 - Supporting error management and safety climate in
ambulatory care practices: the CIRSforte study.
May 1, 2024
Müller BS, Lüttel D, Schütze D, et al. Supporting error management and safety climate in ambulatory care
practices: the CIRSforte study. J Patient Saf. 2024;20(5):314-322. doi:10.1097/pts.0000000000001225.
…
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psnet.ahrq.gov/node/37294/psn-pdf
May 21, 2013 - Improving Hand-Off Communication.
May 21, 2013
Oakbrook Terrace lL: Joint Commission Resources; 2007. ISBN 9781599400907.
https://psnet.ahrq.gov/issue/improving-hand-communication
The process of transferring primary responsibility for patient care is commonly referred to as a handoff.
Handoffs are inherently dange…
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psnet.ahrq.gov/node/47589/psn-pdf
January 09, 2019 - Framework for Effective Board Governance of Health
System Quality.
January 9, 2019
Daley Ullem E, Gandhi TK, Mate K, et al. IHI White Paper. Boston, MA: Institute for Healthcare
Improvement; 2018.
https://psnet.ahrq.gov/issue/framework-effective-board-governance-health-system-quality
The role of hospital boards i…
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psnet.ahrq.gov/node/45000/psn-pdf
August 15, 2016 - Medicare and Medicaid Programs; Hospital and Critical
Access Hospital (CAH) Changes to Promote Innovation,
Flexibility, and Improvement in Patient Care; Proposed
Rule.
June 29, 2016
Centers for Medicare & Medicaid Services. Fed Regist. 2016;81:39447-39480.
https://psnet.ahrq.gov/issue/medicare-and-medicaid-progra…
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psnet.ahrq.gov/node/35220/psn-pdf
May 14, 2015 - Patient Safety and Quality Improvement Act of 2005.
May 14, 2015
Pub L No. 109-41.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005
This bill amends the Public Health Service Act to encourage a culture of safety in health care organizations.
The bill, signed into law July 29, 2005…
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psnet.ahrq.gov/node/46572/psn-pdf
January 01, 2018 - Effects of efforts to optimise morbidity and mortality
rounds to serve contemporary quality improvement and
educational goals: a systematic review.
December 21, 2017
Smaggus A, Mrkobrada M, Marson A, et al. Effects of efforts to optimise morbidity and mortality rounds to
serve contemporary quality improvement and …
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psnet.ahrq.gov/issue/quality-special-issue
April 13, 2022 - Special or Theme Issue
Quality Special Issue.
Citation Text:
Quality Special Issue. J Med Imaging Radiat Oncol. 2022;66(2):165-309.
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psnet.ahrq.gov/issue/can-wearable-tech-prevent-healthcare-errors
December 02, 2020 - Newspaper/Magazine Article
Can wearable tech prevent healthcare errors?
Citation Text:
Can wearable tech prevent healthcare errors? Reese SM. Information Week. March 11, 2014.
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December 19, 2018 - Book/Report
Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care.
Citation Text:
Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. Nance JJ. Boseman, MT: Second River Healthcare Press; 2008. ISBN: 9780974386058.
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