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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46606/psn-pdfJuly 10, 2019 - Implementation of a mock root cause analysis to provide simulated patient safety training. July 10, 2019 Murphy M, Duff J, Whitney J, et al. Implementation of a mock root cause analysis to provide simulated patient safety training. BMJ Open Qual. 2017;6(2). doi:10.1136/bmjoq-2017-000096. https://psnet.ahrq.gov/iss… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/861774/psn-pdfJanuary 31, 2024 - Grand rounds in methodology: key considerations for implementing machine learning solutions in quality improvement initiatives. January 31, 2024 Verma AA, Trbovich PL, Mamdani MM, et al. Grand rounds in methodology: key considerations for implementing machine learning solutions in quality improvement initiatives. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866109/psn-pdfJune 12, 2024 - Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation improvement matrix. June 12, 2024 Bos K, van der Laan MJ, Groeneweg J, et al. Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation improvement matrix. BMJ Open Qual. 2024… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/862131/psn-pdfFebruary 07, 2024 - Prospective study of the multisite spread of a medication safety intervention: factors common to hospitals with improved outcomes. February 7, 2024 Kaplan HC, Goldstein SL, Rubinson C, et al. Prospective study of the multisite spread of a medication safety intervention: factors common to hospitals with improved ou… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/61122/psn-pdfJanuary 01, 2022 - Implementing high-reliability organization principles into practice: a rapid evidence review. November 11, 2020 Veazie S, Peterson K, Bourne D, et al. Implementing high-reliability organization principles into practice: a rapid evidence review. J Patient Saf. 2022;18(1):e320-e328. doi:10.1097/pts.0000000000000768. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837039/psn-pdfMay 04, 2022 - The Joint Commission's new and revised workplace violence prevention standards for hospitals: a major step forward toward improved quality and safety. May 4, 2022 Arnetz JE. The Joint Commission's new and revised workplace violence prevention standards for hospitals: a major step forward toward improved quality an… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/74080/psn-pdfJanuary 01, 2022 - The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center. November 17, 2021 Krishnan S, Wheeler KK, Pimentel MP, et al. The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/61091/psn-pdfNovember 04, 2020 - Prioritising recommendations following analyses of adverse events in healthcare: a systematic review. November 4, 2020 Bos K, van der Laan MJ, Dongelmans DA. Prioritising recommendations following analyses of adverse events in healthcare: a systematic review. BMJ Open Qual. 2020;9(4):e000843. doi:10.1136/bmjoq-2019… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72790/psn-pdfMarch 03, 2021 - Parent engagement in perinatal mortality reviews: an online survey of clinicians from six high-income countries. March 3, 2021 Boyle FM, Horey D, Siassakos D, et al. Parent engagement in perinatal mortality reviews: an online survey of clinicians from six high?income countries. BJOG. 2020;128(4):696-703. doi:10.11… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/836960/psn-pdfApril 20, 2022 - Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality. April 20, 2022 Fitzgerald KM, Banerjee TR, Starmer AJ, et al. Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality. Pediatr Qual Saf. 2022;7(2):e539. doi:10.1097/pq9.0000000000000539. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/849610/psn-pdfMay 31, 2023 - Implementation of ED I-PASS as a standardized handoff tool in the pediatric emergency department. May 31, 2023 Yanni E, Calaman S, Wiener E, et al. Implementation of ED I-PASS as a standardized handoff tool in the pediatric emergency department. J Healthc Qual. 2023;45(3):140-147. doi:10.1097/jhq.0000000000000374.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45519/psn-pdfNovember 01, 2017 - Morbidity and mortality conferences: a narrative review of strategies to prioritize quality improvement. November 1, 2017 Giesbrecht V, Au S. Morbidity and Mortality Conferences: A Narrative Review of Strategies to Prioritize Quality Improvement. Jt Comm J Qual Patient Saf. 2016;42(11):516-527. doi:10.1016/S1553- … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40191/psn-pdfMay 28, 2014 - The Value of Close Calls in Improving Patient Safety. May 28, 2014 Wu AW, ed. Oakbrook Terrace, IL: Joint Commission Resources; 2011. ISBN: 9781599404158. https://psnet.ahrq.gov/issue/value-close-calls-improving-patient-safety Close calls (sometimes called near misses) pose unique challenges and opportunities when … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46739/psn-pdfJanuary 24, 2019 - Symptom–Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data. January 24, 2019 Liberman AL, Newman-Toker DE. Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodologica… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47327/psn-pdfAugust 22, 2018 - US internal medicine program director perceptions of alignment of graduate medical education and institutional resources for engaging residents in quality and safety. August 22, 2018 Chacko KM, Halvorsen AJ, Swenson SL, et al. US Internal Medicine Program Director Perceptions of Alignment of Graduate Medical Educa… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46467/psn-pdfOctober 18, 2017 - The Role of Clinical Learning Environments in Preparing New Clinicians to Engage in Patient Safety. October 18, 2017 Disch J, Kilo CM, Passiment M, Wagner R, Weiss KB; National Collaborative for Improving the Clinical Learning Environment. Chicago, IL: Accreditation Council for Graduate Medical Education; 2017. ht… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44753/psn-pdfApril 12, 2019 - Is bias in the eye of the beholder? A vignette study to assess recognition of cognitive biases in clinical case workups. April 12, 2019 Zwaan L, Monteiro SD, Sherbino J, et al. Is bias in the eye of the beholder? A vignette study to assess recognition of cognitive biases in clinical case workups. BMJ Qual Saf. 201… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/857581/psn-pdfJanuary 01, 2025 - Medicare and Medicaid Programs and the Children’s Health Insurance Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long- Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2025 Rates; Quality Programs Requirements; and Other Policy Changes. Au… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37348/psn-pdfMarch 28, 2012 - Impact of duty hours restrictions on quality of care and clinical outcomes. March 28, 2012 Bhavsar J, Montgomery D, Li J, et al. Impact of duty hours restrictions on quality of care and clinical outcomes. Am J Med. 2007;120(11):968-74. https://psnet.ahrq.gov/issue/impact-duty-hours-restrictions-quality-care-and-cl… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39602/psn-pdfAugust 09, 2013 - Postoperative handover: problems, pitfalls, and prevention of error. August 9, 2013 Nagpal K, Arora S, Abboudi M, et al. Postoperative handover: problems, pitfalls, and prevention of error. Ann Surg. 2010;252(1):171-6. doi:10.1097/SLA.0b013e3181dc3656. https://psnet.ahrq.gov/issue/postoperative-handover-problems-p…
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