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psnet.ahrq.gov/issue/becoming-high-reliability-organization
May 04, 2015 - Special or Theme Issue
Becoming a High Reliability Organization.
Citation Text:
Becoming a High Reliability Organization. VHA Forum. Summer 2020;1-12.
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - Spotlight
Too Many Cooks in the Kitchen
Source and Credits
• This presentation is based on the August 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Richard P. Dutton, MD, MBA
o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…
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psnet.ahrq.gov/node/33786/psn-pdf
May 01, 2015 - Video to Improve Patient Safety: Clinical and Educational
Uses
May 1, 2015
Xiao Y, Mackenzie CF, Seagull JF. Video to Improve Patient Safety: Clinical and Educational Uses. PSNet
[internet]. 2015.
https://psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
Perspective
Reports of…
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psnet.ahrq.gov/web-mm/staggered-sensitivity-results
May 01, 2013 - Staggered Sensitivity Results
Citation Text:
Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
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psnet.ahrq.gov/node/848125/psn-pdf
April 26, 2023 - Surveillance Monitoring to Improve Patient Safety in
Acute Hospital Care Units
April 26, 2023
McGrath S, Blike G, Gale B, et al. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care
Units. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-…
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psnet.ahrq.gov/node/49654/psn-pdf
June 01, 2012 - Transfer Troubles
June 1, 2012
Hains IM. Transfer Troubles. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/transfer-troubles
Case Objectives
Recognize that transfer of patients between hospitals is common.
Understand the frequency of errors and adverse events in the transfer of patients between hospitals.
…
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psnet.ahrq.gov/node/33663/psn-pdf
September 15, 2008 - Implementing a Patient Safety Program at a Large
National Health System
January 1, 2008
Hauck LD, Jacob J. Implementing a Patient Safety Program at a Large National Health System. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system
Perspectiv…
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psnet.ahrq.gov/web-mm/communication-error-closed-icu
July 01, 2016 - Communication Error in a Closed ICU
Citation Text:
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/perspective/conversation-withsorrel-king
March 01, 2007 - In Conversation with...Sorrel King
March 1, 2007
Also Read an Essay
Citation Text:
In Conversation with..Sorrel King. PSNet [internet]. 2007.In Conversation with...Sorrel King. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep
January 1, 2019
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
Case Objectives
List the patient safety events that are unique to in…
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psnet.ahrq.gov/node/865466/psn-pdf
March 27, 2024 - Equity in Patient Safety
March 27, 2024
Thomas A, Lee M, Mossburg S. Equity in Patient Safety. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/equity-patient-safety
Introduction
Safety and equity are among the central components that determine quality of care, according to nonprofit
advisory agencies l…
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psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
July 23, 2024 - A Statewide Collaborative to Support Vaginal Birth and Reduce Unnecessary Cesarean Deliveries
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July 8, 2022
Innovation
Contact
…
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psnet.ahrq.gov/node/844766/psn-pdf
January 01, 2020 - Validation of new ICD-10-based patient safety indicators
for identification of in-hospital complications in surgical
patients: a study of diagnostic accuracy.
September 11, 2019
McIsaac DI, Hamilton GM, Abdulla K, et al. Validation of new ICD-10-based patient safety indicators for
identification of in-hospital com…
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psnet.ahrq.gov/node/37771/psn-pdf
June 29, 2011 - Effect of crew resource management training in a
multidisciplinary obstetrical setting.
June 29, 2011
Haller G, Garnerin P, Morales M-A, et al. Effect of crew resource management training in a multidisciplinary
obstetrical setting. Int J Qual Health Care. 2008;20(4):254-63. doi:10.1093/intqhc/mzn018.
https://psnet…
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psnet.ahrq.gov/node/61110/psn-pdf
November 11, 2020 - Association between parent comfort with English and
adverse events among hospitalized children.
November 11, 2020
Khan A, Yin HS, Brach C, et al. Association between parent comfort with English and adverse events
among hospitalized children. JAMA Pediatr. 2020;174(12):e203215.
doi:10.1001/jamapediatrics.2020.3215.…
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psnet.ahrq.gov/node/45437/psn-pdf
September 01, 2018 - Decreasing malpractice claims by reducing preventable
perinatal harm.
September 1, 2018
Riley W, Meredith LW, Price R, et al. Decreasing Malpractice Claims by Reducing Preventable Perinatal
Harm. Health Serv Res. 2016;51(suppl 3):2453-2471. doi:10.1111/1475-6773.12551.
https://psnet.ahrq.gov/issue/decreasing-malpr…
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psnet.ahrq.gov/node/41983/psn-pdf
January 16, 2013 - A systematic review of evidence on the links between
patient experience and clinical safety and effectiveness.
January 16, 2013
Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and
clinical safety and effectiveness. BMJ Open. 2013;3(1). doi:10.1136/bmjopen-2012-0015…
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psnet.ahrq.gov/node/41986/psn-pdf
January 23, 2013 - Slow progress on meeting hospital safety standards:
learning from the Leapfrog Group's efforts.
January 23, 2013
Moran J, Scanlon D. Slow progress on meeting hospital safety standards: learning from the Leapfrog
Group's efforts. Health Aff (Millwood). 2013;32(1):27-35. doi:10.1377/hlthaff.2011.0056.
https://psnet.…
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psnet.ahrq.gov/node/46236/psn-pdf
April 03, 2018 - The impact of a diagnostic decision support system on
the consultation: perceptions of GPs and patients.
April 3, 2018
Porat T, Delaney B, Kostopoulou O. The impact of a diagnostic decision support system on the
consultation: perceptions of GPs and patients. BMC Med Inform Decis Mak. 2017;17(1):79.
doi:10.1186/s12…
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psnet.ahrq.gov/node/39210/psn-pdf
January 12, 2010 - Can aviation-based team training elicit sustainable
behavioral change?
January 12, 2010
Sax HC, Browne P, Mayewski RJ, et al. Can aviation-based team training elicit sustainable behavioral
change? Arch Surg. 2009;144(12):1133-1137. doi:10.1001/archsurg.2009.207.
https://psnet.ahrq.gov/issue/can-aviation-based-team…