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Showing results for "improves".

  1. Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? | PSNet

    psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve-patient-safety
    October 23, 2013 - Study Classic Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? Citation Text: Kellogg KM, Hettinger Z, Shah M, et al. Our current approach to root cause analysis: is it contributing to our failure to impro…

  2. The Veterans Affairs root cause analysis system in action. | PSNet

    psnet.ahrq.gov/issue/veterans-affairs-root-cause-analysis-system-action
    June 22, 2022 - Study Classic The Veterans Affairs root cause analysis system in action. Citation Text: Bagian JP, Gosbee JW, Lee CZ, et al. The Veterans Affairs Root Cause Analysis System in Action. Jt Comm J Qual Improv. 2016;28(10):531-545. doi:10.1016/s1070-3241(02)28057-8.…

  3. Effect of a pediatric early warning system on all-cause mortality in hospitalized pediatric patients. | PSNet

    psnet.ahrq.gov/issue/effect-pediatric-early-warning-system-all-cause-mortality-hospitalized-pediatric-patients
    April 24, 2018 - Study Classic Effect of a pediatric early warning system on all-cause mortality in hospitalized pediatric patients. Citation Text: Parshuram CS, Dryden-Palmer K, Farrell C, et al. Effect of a Pediatric Early Warning System on All-Cause Mortality in Hospitalized …

  4. Why is learning from patient safety incidents (still) so hard? A sociocultural perspective on learning from incidents in healthcare organizations. | PSNet

    psnet.ahrq.gov/issue/why-learning-patient-safety-incidents-still-so-hard-sociocultural-perspective-learning
    June 29, 2011 - Study Why is learning from patient safety incidents (still) so hard? A sociocultural perspective on learning from incidents in healthcare organizations. Citation Text: Rowland P, Lan MF, Wan C, et al. Why is learning from patient safety incidents (still) so hard? A sociocultural perspect…

  5. Designing an intervention to improve medication safety for nursing home residents based on experiential knowledge related to patient safety culture at the nursing home front line: cocreative process study. | PSNet

    psnet.ahrq.gov/issue/designing-intervention-improve-medication-safety-nursing-home-residents-based-experiential
    February 14, 2024 - Commentary Designing an intervention to improve medication safety for nursing home residents based on experiential knowledge related to patient safety culture at the nursing home front line: cocreative process study. Citation Text: Juhl MH, Soerensen AL, Vardinghus-Nielsen H, et al. Desi…

  6. Interventions into reliability-seeking health care organizations: a systematic review of their goals and measuring methods. | PSNet

    psnet.ahrq.gov/issue/interventions-reliability-seeking-health-care-organizations-systematic-review-their-goals-and
    October 19, 2022 - Review Interventions into reliability-seeking health care organizations: a systematic review of their goals and measuring methods. Citation Text: Auschra C, Asaad E, Sydow J, et al. Interventions into reliability-seeking health care organizations: a systematic review of their goals and m…

  7. The impact of an intervention to improve intrapartum maternal vital sign monitoring and reduce alarm fatigue. | PSNet

    psnet.ahrq.gov/issue/impact-intervention-improve-intrapartum-maternal-vital-sign-monitoring-and-reduce-alarm
    September 23, 2020 - Study The impact of an intervention to improve intrapartum maternal vital sign monitoring and reduce alarm fatigue. Citation Text: Kern-Goldberger AR, Nicholls EM, Plastino N, et al. The impact of an intervention to improve intrapartum maternal vital sign monitoring and reduce alarm fati…

  8. Effects of the I-PASS nursing handoff bundle on communication quality and workflow. | PSNet

    psnet.ahrq.gov/issue/effects-i-pass-nursing-handoff-bundle-communication-quality-and-workflow
    November 12, 2014 - Study Effects of the I-PASS nursing handoff bundle on communication quality and workflow. Citation Text: Starmer AJ, Schnock KO, Lyons A, et al. Effects of the I-PASS Nursing Handoff Bundle on communication quality and workflow. BMJ Qual Saf. 2017;26(12):949-957. doi:10.1136/bmjqs-2016-0…

  9. National improvements in resident physician-reported patient safety after limiting first-year resident physicians' extended duration work shifts: a pooled analysis of prospective cohort studies. | PSNet

    psnet.ahrq.gov/issue/national-improvements-resident-physician-reported-patient-safety-after-limiting-first-year
    July 15, 2020 - Study National improvements in resident physician-reported patient safety after limiting first-year resident physicians' extended duration work shifts: a pooled analysis of prospective cohort studies. Citation Text: Weaver MD, Landrigan CP, Sullivan JP, et al. National improvements in re…

  10. Culture change in infection control: applying psychological principles to improve hand hygiene. | PSNet

    psnet.ahrq.gov/issue/culture-change-infection-control-applying-psychological-principles-improve-hand-hygiene
    November 21, 2021 - Study Culture change in infection control: applying psychological principles to improve hand hygiene. Citation Text: Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013;28(4):304…

  11. Operating room–to-ICU patient handovers: a multidisciplinary human-centered design approach. | PSNet

    psnet.ahrq.gov/issue/operating-room-icu-patient-handovers-multidisciplinary-human-centered-design-approach
    June 27, 2012 - Study Operating room–to-ICU patient handovers: a multidisciplinary human-centered design approach. Citation Text: Segall N, Bonifacio AS, Barbeito A, et al. Operating Room-to-ICU Patient Handovers: A Multidisciplinary Human-Centered Design Approach. Jt Comm J Qual Patient Saf. 2016;42(9)…

  12. Computerized triggers of big data to detect delays in follow-up of chest imaging results. | PSNet

    psnet.ahrq.gov/issue/computerized-triggers-big-data-detect-delays-follow-chest-imaging-results
    March 19, 2018 - Study Computerized triggers of big data to detect delays in follow-up of chest imaging results. Citation Text: Murphy DR, Meyer AND, Bhise V, et al. Computerized Triggers of Big Data to Detect Delays in Follow-up of Chest Imaging Results. Chest. 2016;150(3):613-20. doi:10.1016/j.chest.20…

  13. Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? | PSNet

    psnet.ahrq.gov/issue/notification-abnormal-lab-test-results-electronic-medical-record-do-any-safety-concerns
    April 04, 2011 - Study Classic Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? Citation Text: Singh H, Thomas EJ, Sittig DF, et al. Notification of abnormal lab test results in an electronic medical record: do any safet…

  14. Influencing a culture of quality and safety through huddles. | PSNet

    psnet.ahrq.gov/issue/influencing-culture-quality-and-safety-through-huddles
    April 05, 2023 - Study Influencing a culture of quality and safety through huddles. Citation Text: McCain N, Ferguson T, Barry Hultquist T, et al. Influencing a culture of quality and safety through huddles. J Nurs Care Qual. 2023;38(1):26-32. doi:10.1097/ncq.0000000000000642. Copy Citation Format:…

  15. Adverse events in long-term care residents transitioning from hospital back to nursing home. | PSNet

    psnet.ahrq.gov/issue/adverse-events-long-term-care-residents-transitioning-hospital-back-nursing-home
    April 28, 2021 - Study Adverse events in long-term care residents transitioning from hospital back to nursing home. Citation Text: Kapoor A, Field T, Handler S, et al. Adverse Events in Long-term Care Residents Transitioning From Hospital Back to Nursing Home. JAMA Intern Med. 2019;179(9):1254-1261. doi:…

  16. A program to provide clinicians with feedback on their diagnostic performance in a learning health system. | PSNet

    psnet.ahrq.gov/issue/program-provide-clinicians-feedback-their-diagnostic-performance-learning-health-system
    October 12, 2022 - Study A program to provide clinicians with feedback on their diagnostic performance in a learning health system. Citation Text: Meyer AND, Upadhyay DK, Collins CA, et al. A program to provide clinicians with feedback on their diagnostic performance in a learning health system. Jt Comm J …

  17. Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: retrospective cohort study. | PSNet

    psnet.ahrq.gov/issue/changes-hospital-safety-following-penalties-us-hospital-acquired-condition-reduction-program
    September 29, 2021 - Study Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: retrospective cohort study. Citation Text: Sankaran R, Sukul D, Nuliyalu U, et al. Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction …

  18. Psn-Pdf (pdf file)

    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…

  19. Home | PSNet

    psnet.ahrq.gov/
    March 25, 2025 - This website is up to date as of March 24, 2025. You will not be able to register for an account and will no longer be able to obtain Continuing Medical Education (CME), Maintenance of Certification (MOC), or Continuing Pharmacy Education (CPE) credits. We are not taking submissions for WebM&M cases, Innovations, Train…

  20. Psn-Pdf (pdf file)

    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…
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