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psnet.ahrq.gov/node/45569/psn-pdf
January 23, 2017 - Patient experience must move beyond bad apples.
January 23, 2017
Hamedani A, Safdar B, Aaronson E, et al. Patient Experience Must Move Beyond Bad Apples. Ann Intern
Med. 2016;165(12):869-870. doi:10.7326/M16-1725.
https://psnet.ahrq.gov/issue/patient-experience-must-move-beyond-bad-apples
Patient safety leaders ha…
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psnet.ahrq.gov/node/38929/psn-pdf
April 01, 2010 - Effectiveness of patient care teams and the role of clinical
expertise and coordination: a literature review.
April 1, 2010
Bosch M, Faber MJ, Cruijsberg J, et al. Review article: Effectiveness of patient care teams and the role of
clinical expertise and coordination: a literature review. Med Care Res Rev. 2009;66(…
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psnet.ahrq.gov/node/34930/psn-pdf
April 06, 2011 - "Going solid": a model of system dynamics and
consequences for patient safety.
April 6, 2011
Cook R, Rasmussen J. "Going solid": a model of system dynamics and consequences for patient safety.
Qual Saf Health Care. 2005;14(2):130-4.
https://psnet.ahrq.gov/issue/going-solid-model-system-dynamics-and-consequences-pa…
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psnet.ahrq.gov/node/47114/psn-pdf
October 13, 2018 - Focused ethnography of diagnosis in academic medical
centers.
October 13, 2018
Chopra V, Harrod M, Winter S, et al. Focused Ethnography of Diagnosis in Academic Medical Centers. J
Hosp Med. 2018;13(10):668-672. doi:10.12788/jhm.2966.
https://psnet.ahrq.gov/issue/focused-ethnography-diagnosis-academic-medical-cente…
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psnet.ahrq.gov/node/33958/psn-pdf
December 18, 2008 - A review of the literature examining linkages between
organizational factors, medical errors, and patient safety.
December 18, 2008
Hoff T, Jameson L, Hannan E, et al. A review of the literature examining linkages between organizational
factors, medical errors, and patient safety. Med Care Res Rev. 2004;61(1):3-37.…
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psnet.ahrq.gov/node/41227/psn-pdf
March 21, 2012 - Parenteral nutrition prescribing processes using
computerized prescriber order entry: opportunities to
improve safety.
March 21, 2012
Hilmas E, Peoples JD. Parenteral nutrition prescribing processes using computerized prescriber order
entry: opportunities to improve safety. JPEN J Parenter Enteral Nutr. 2012;36(2 …
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psnet.ahrq.gov/node/853980/psn-pdf
September 27, 2023 - RFID tags reduce restocking errors of anesthesia
medications.
September 27, 2023
Banks MA. Specialty Pharmacy Continuum. September 15, 2023.
https://psnet.ahrq.gov/issue/rfid-tags-reduce-restocking-errors-anesthesia-medications
Radiofrequency identification (RFID) devices are being used to improve processes in the…
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psnet.ahrq.gov/node/45918/psn-pdf
May 24, 2017 - Applying human-centered design thinking to enhance
safety in the OR.
May 24, 2017
Criscitelli T, Goodwin W. Applying Human-Centered Design Thinking to Enhance Safety in the OR. AORN
J. 2017;105(4):408-412. doi:10.1016/j.aorn.2017.02.004.
https://psnet.ahrq.gov/issue/applying-human-centered-design-thinking-enhance-…
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psnet.ahrq.gov/node/867450/psn-pdf
January 08, 2025 - Advancing Health Care Safety for All.
January 8, 2025
Advancing Health Care Safety for All. Centers for Medicare and Medicaid Services. 2024.
https://psnet.ahrq.gov/issue/advancing-health-care-safety-all
As one element of a national program to improve care quality, the Centers for Medicare and Medicaid
Services (C…
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psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - One Bronchoscopy, Two Errors
Citation Text:
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
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psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued
January 05, 2017 - Discontinued Medications: Are They Really Discontinued?
Citation Text:
Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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Format:
…
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psnet.ahrq.gov/node/50769/psn-pdf
February 15, 2017 - Cultural Competence and Patient Safety
December 27, 2019
Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
Background
Culture can be defined as the “personal identification, language, thoughts, co…
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psnet.ahrq.gov/node/74215/psn-pdf
October 25, 2011 - Race and the clinical diagnosis of depression in new
primary care patients.
October 25, 2011
Lukachko A, Olfson M. Race and the clinical diagnosis of depression in new primary care patients. Gen
Hosp Psychiatry. 2011;34(1):98-100. doi:10.1016/j.genhosppsych.2011.09.008.
https://psnet.ahrq.gov/issue/race-and-clinic…
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psnet.ahrq.gov/node/72751/psn-pdf
February 17, 2021 - The critical need for nursing education to address the
diagnostic process.
February 17, 2021
Gleason KT, Harkless G, Stanley J, et al. The critical need for nursing education to address the diagnostic
process. Nurs Outlook. 2021;69(3):362-369. doi:10.1016/j.outlook.2020.12.005.
https://psnet.ahrq.gov/issue/critica…
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psnet.ahrq.gov/node/837607/psn-pdf
June 29, 2022 - Common Formats for Event Reporting - Diagnostic Safety
Version 1.0
June 29, 2022
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/common-formats-event-reporting-diagnostic-safety-version-10
Effective measurement of diagnostic error is essential for understanding the problem and genera…
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psnet.ahrq.gov/node/47336/psn-pdf
March 04, 2019 - "Saying sorry": some strategies for effective apology
within the workplace.
March 4, 2019
Cleary M, Lees D, Lopez V. "Saying sorry": some strategies for effective apology within the workplace.
Issues Ment Health Nurs. 2018;39(11):980-982. doi:10.1080/01612840.2018.1507571.
https://psnet.ahrq.gov/issue/saying-sorry…
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psnet.ahrq.gov/node/844551/psn-pdf
February 15, 2023 - Emotional safety is patient safety.
February 15, 2023
Lyndon A, Davis D-A, Sharma AE, et al. Emotional safety is patient safety. BMJ Qual Saf. 2023;32(7):369-
372. doi:10.1136/bmjqs-2022-015573.
https://psnet.ahrq.gov/issue/emotional-safety-patient-safety
Patient perspectives can provide unique insights into care …
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psnet.ahrq.gov/node/855103/psn-pdf
November 08, 2023 - Adverse Events.
November 8, 2023
United States Office of the Inspector General: 2010-2023.
https://psnet.ahrq.gov/issue/adverse-events-0
Large-scale data analysis provides insights to generate evidence-based improvement action. This
collection of reports provides access to investigations of the impact of heal…
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psnet.ahrq.gov/node/866524/psn-pdf
August 14, 2024 - Generative artificial intelligence, patient safety and
healthcare quality: a review.
August 14, 2024
Howell MD. Generative artificial intelligence, patient safety and healthcare quality: a review. BMJ Qual Saf.
2024;33(11):748-754. doi:10.1136/bmjqs-2023-016690.
https://psnet.ahrq.gov/issue/generative-artificial-i…
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psnet.ahrq.gov/node/60156/psn-pdf
March 25, 2020 - The cognitive health system.
March 25, 2020
Coiera E. The cognitive health system. Lancet. 2020;395(10222):463-466. doi:10.1016/s0140-
6736(19)32987-3.
https://psnet.ahrq.gov/issue/cognitive-health-system
This article discusses the influence of artificial intelligence tools and cyber-social systems on human
decis…