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psnet.ahrq.gov/issue/integrating-principles-safety-culture-and-just-culture-nursing-homes-lessons-pandemic
October 28, 2020 - Commentary
Integrating principles of safety culture and just culture into nursing homes: lessons from the pandemic.
Citation Text:
Gaur S, Kumar R, Gillespie SM, et al. Integrating Principles of Safety Culture and Just Culture Into Nursing Homes: Lessons From the Pandemic. J Am Med Dir A…
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psnet.ahrq.gov/issue/changes-safety-and-teamwork-climate-after-adding-structured-observations-patient-safety
August 20, 2018 - Study
Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds.
Citation Text:
Klimmeck S, Sexton B, Schwendimann R. Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds. Jt Comm J Qual Pa…
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psnet.ahrq.gov/issue/sustaining-and-spreading-reduction-adverse-drug-events-multicenter-collaborative
November 16, 2022 - Study
Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative.
Citation Text:
Tham E, Calmes HM, Poppy A, et al. Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative. Pediatrics. 2011;128(2):e438-45. doi:10.1542…
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psnet.ahrq.gov/issue/quality-framework-remote-antenatal-care-qualitative-study-women-healthcare-professionals-and
October 21, 2020 - Study
Quality framework for remote antenatal care: qualitative study with women, healthcare professionals and system-level stakeholders.
Citation Text:
Hinton L, Dakin FH, Kuberska K, et al. Quality framework for remote antenatal care: qualitative study with women, healthcare professiona…
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psnet.ahrq.gov/issue/preventable-adverse-drug-events-hospitalized-patients-comparative-study-intensive-care-and
March 31, 2021 - Study
Classic
Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units.
Citation Text:
Cullen DJ, Sweitzer BJ, Bates DW, et al. Preventable adverse drug events in hospitalized patients. Crit Care Me…
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psnet.ahrq.gov/issue/perceptions-us-and-uk-incident-reporting-systems-scoping-review
January 19, 2022 - Review
Perceptions of U.S. and U.K. incident reporting systems: a scoping review.
Citation Text:
Gampetro PJ, Nickum A, Schultz CM. Perceptions of U.S. and U.K. incident reporting systems: a scoping review. J Patient Saf. 2024;20(5):360-365. doi:10.1097/pts.0000000000001231.
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psnet.ahrq.gov/issue/triggers-contributing-health-care-clinicians-disruptive-behaviors
June 24, 2020 - Study
Triggers contributing to health care clinicians' disruptive behaviors.
Citation Text:
Bae S-H, Dang D, Karlowicz KA, et al. Triggers contributing to health care clinicians' disruptive behaviors. J Patient Saf. 2020;16(3):e148-e155. doi:10.1097/pts.0000000000000288.
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psnet.ahrq.gov/issue/improving-medication-safety-paediatric-hospital-mixed-methods-evaluation-newly-implemented
August 30, 2023 - Study
Improving medication safety in a paediatric hospital: a mixed-methods evaluation of a newly implemented computerised provider order entry system.
Citation Text:
Improving medication safety in a paediatric hospital: a mixed-methods evaluation of a newly implemented computerised prov…
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psnet.ahrq.gov/issue/machine-learning-approach-reclassifying-miscellaneous-patient-safety-event-reports
July 22, 2020 - Study
A machine learning approach to reclassifying miscellaneous patient safety event reports.
Citation Text:
Fong A, Behzad S, Pruitt Z, et al. A machine learning approach to reclassifying miscellaneous patient safety event reports. J Patient Saf. 2021;17(8):e829-e833. doi:10.1097/pts.0…
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psnet.ahrq.gov/node/37660/psn-pdf
April 02, 2008 - An interdisciplinary approach to safer blood transfusion.
April 2, 2008
LaRocco M, Brient K. Patient Saf Qual Healthc. March April 2008.
https://psnet.ahrq.gov/issue/interdisciplinary-approach-safer-blood-transfusion
This article reports on one hospital's efforts to improve blood transfusion safety by implementing …
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psnet.ahrq.gov/node/35155/psn-pdf
April 03, 2008 - Safer Healthcare Now!
April 3, 2008
Canadian Patient Safety Institute.
https://psnet.ahrq.gov/issue/safer-healthcare-now
Originally launched in 2005, this campaign seeks to implement evidence-based strategies to improve
patient safety in Canadian hospitals. In April 2008, the initiative added four new intervention…
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - SPOTLIGHT CASE
Which Line: Ordering Provider or Proceduralist?
Citation Text:
Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format: …
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psnet.ahrq.gov/node/72613/psn-pdf
December 22, 2020 - In Conversation With... Elsabeth Kalenderian, DDS, MPH,
PhD and Muhammad F. Walji, PhD
December 22, 2020
In Conversation With.. Elsabeth Kalenderian, DDS, MPH, PhD and Muhammad F. Walji, PhD. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-elsabeth-kalenderian-dds-mph-phd-and-muhammad-f-
w…
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psnet.ahrq.gov/node/49843/psn-pdf
October 01, 2018 - Spotlight: Overdiagnosis and Delay: Challenges in Sepsis
Diagnosis
October 1, 2018
Kuye I, Rhee C. Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis. PSNet [internet].
2018.
https://psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
Case Objectives
Realize the im…
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psnet.ahrq.gov/primer/debriefing-clinical-learning
September 15, 2024 - Debriefing for Clinical Learning
Citation Text:
Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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Format:
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psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
March 15, 2023 - Challenges of Diabetes Management and Medication Reconciliation
Citation Text:
Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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…
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psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
March 01, 2017 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety
Sara J. Singer, MBA, PhD | September 1, 2013
View more articles from the same authors.
Citation Text:
Singer SJ. What We've Learned About Leveraging Leadership a…
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience
Karen Frush, MD | May 1, 2005
View more articles from the same authors.
Citation Text:
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
March 01, 2009 - Spotlight Case July 2008
Spotlight Case
All in the History
Source and Credits
This presentation is based on the February/March 2009 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Christopher Fee, MD, University of California, San Francisco
…
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psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
January 01, 2020 - Spotlight
Spotlight
Inpatient Stroke Management in a Patient
with Type 1 Diabetes and Home Insulin
Pump
Source and Credits
• This presentation is based on the October 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: Berit B…