-
psnet.ahrq.gov/node/50425/psn-pdf
September 04, 2019 - Why doctors still offer treatments that may not help.
September 4, 2019
Frakt A. New York Times. August 26, 2019.
https://psnet.ahrq.gov/issue/why-doctors-still-offer-treatments-may-not-help
The slow adoption of improvement innovations is a persistent challenge to high-quality and safe patient
care. This newspaper…
-
psnet.ahrq.gov/node/44420/psn-pdf
August 26, 2015 - Obstetric safety and quality.
August 26, 2015
Pettker CM, Grobman WA. Obstetric Safety and Quality. Obstet Gynecol. 2015;126(1):196-206.
doi:10.1097/AOG.0000000000000918.
https://psnet.ahrq.gov/issue/obstetric-safety-and-quality
Obstetric hospital admission has substantial potential for harm should something go wr…
-
psnet.ahrq.gov/node/47067/psn-pdf
May 16, 2018 - Senior staff safety rounds: a commitment to ensure safety
is the top priority.
May 16, 2018
O'Connell RT, Ivy ME. NEJM Catalyst. May 1, 2018.
https://psnet.ahrq.gov/issue/senior-staff-safety-rounds-commitment-ensure-safety-top-priority
Leadership participation at the front lines can drive safety improvement work. …
-
psnet.ahrq.gov/node/43219/psn-pdf
January 01, 2015 - Developing a reporting and tracking tool for nursing
student errors and near misses.
May 28, 2014
Disch J, Barnsteiner J. Developing a Reporting and Tracking Tool for Nursing Student Errors and Near
Misses. J Nurs Reg. 2015;5(1):4-10. doi:10.1016/s2155-8256(15)30093-4.
https://psnet.ahrq.gov/issue/developing-repor…
-
psnet.ahrq.gov/node/46963/psn-pdf
April 18, 2018 - A Just Culture Guide.
April 18, 2018
NHS Improvement. London, UK: National Health Service; March 15, 2018.
https://psnet.ahrq.gov/issue/just-culture-guide
Although focusing on system failure has been highlighted as key to improving patient safety, individual
behaviors must also be recognized as contributors to ris…
-
psnet.ahrq.gov/node/47766/psn-pdf
March 27, 2019 - Advancing the Safety of Acute Pain Management.
March 27, 2019
Boston, MA: Institute for Healthcare Improvement; 2019.
https://psnet.ahrq.gov/issue/advancing-safety-acute-pain-management
Pain management has emerged as a complex safety concern. This report discusses four organizational
prerequisites to improve pain …
-
psnet.ahrq.gov/node/46240/psn-pdf
June 21, 2017 - Implementation of a modified bedside handoff for a
postpartum unit.
June 21, 2017
Wollenhaup CA, Stevenson EL, Thompson J, et al. Implementation of a Modified Bedside Handoff for a
Postpartum Unit. J Nurs Admin. 2017;47(6):320-326. doi:10.1097/NNA.0000000000000487.
https://psnet.ahrq.gov/issue/implementation-modif…
-
psnet.ahrq.gov/node/45612/psn-pdf
November 09, 2016 - Pharmacist work stress and learning from quality related
events.
November 9, 2016
Boyle TA, Bishop A, Morrison B, et al. Pharmacist work stress and learning from quality related events. Res
Social Adm Pharm. 2016;12(5):772-83. doi:10.1016/j.sapharm.2015.10.003.
https://psnet.ahrq.gov/issue/pharmacist-work-stress-a…
-
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…
-
psnet.ahrq.gov/node/44871/psn-pdf
April 22, 2016 - Making checklists work: South Carolina's statewide
experiment.
April 22, 2016
Rice S. MAKING CHECKLISTS WORK. Modern healthcare. 2016;46(4):14-6.
https://psnet.ahrq.gov/issue/making-checklists-work-south-carolinas-statewide-experiment
Although checklist implementation as a safety strategy has achieved some success…
-
psnet.ahrq.gov/node/45531/psn-pdf
December 14, 2016 - The role of safety culture in influencing provider
perceptions of patient safety.
December 14, 2016
Bishop A, Boyle TA. The Role of Safety Culture in Influencing Provider Perceptions of Patient Safety. J
Patient Saf. 2016;12(4):204-209.
https://psnet.ahrq.gov/issue/role-safety-culture-influencing-provider-percepti…
-
psnet.ahrq.gov/node/45565/psn-pdf
May 24, 2017 - Leading a Culture of Safety: a Blueprint for Success.
May 24, 2017
Chicago, IL: American College of Healthcare Executives, National Patient Safety Foundation's Lucian
Leape Institute; 2017.
https://psnet.ahrq.gov/issue/leading-culture-safety-blueprint-success
Health care leadership plays an undeniable role in sust…
-
psnet.ahrq.gov/node/73894/psn-pdf
February 22, 2022 - Achieving Excellence in Cancer Diagnosis: Proceedings
of a Workshop—in Brief.
February 22, 2022
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National
Academies Press; 2022.
https://psnet.ahrq.gov/issue/achieving-excellence-cancer-diagnosis
Diagnostic errors remain an o…
-
psnet.ahrq.gov/node/48068/psn-pdf
June 12, 2019 - Health Professions Education.
June 12, 2019
Dhaliwal G, Olson APJ, Singhal G, eds. Diagnosis (Berl). 2019;6(2):75-185.
https://psnet.ahrq.gov/issue/health-professions-education
Clinical and educational environments are increasingly focusing on improving diagnosis. This special issue
explores an overarching approac…
-
psnet.ahrq.gov/node/60040/psn-pdf
March 11, 2020 - Shifting the Mindset: A Closer Look at Hospital
Complaints.
March 11, 2020
Newcastle upon Tyne, UK: Healthwatch; January 2020.
https://psnet.ahrq.gov/issue/shifting-mindset-closer-look-hospital-complaints
Organizations need to do more than report and collect complaint data to realize improvements based on
what is…
-
psnet.ahrq.gov/node/48067/psn-pdf
June 12, 2019 - Maternal sleepiness and risk of infant drops in the
postpartum period.
June 12, 2019
Bittle MD, Knapp H, Polomano RC, et al. Maternal Sleepiness and Risk of Infant Drops in the Postpartum
Period. Jt Comm J Qual Patient Saf. 2019;45(5):337-347. doi:10.1016/j.jcjq.2018.12.001.
https://psnet.ahrq.gov/issue/maternal-s…
-
psnet.ahrq.gov/node/60975/psn-pdf
September 30, 2020 - Evidence on Use of Clinical Reasoning Checklists for
Diagnostic Error Reduction.
September 30, 2020
Zwaan L, Staal J. Rockville, MD: Agency for Healthcare Research and Quality; September 2020.
AHRQ Publication No. 20-0040-3-EF.
https://psnet.ahrq.gov/issue/evidence-use-clinical-reasoning-checklists-diagnostic…
-
psnet.ahrq.gov/node/72559/psn-pdf
December 09, 2020 - The Life and Death of Elizabeth Dixon: A Catalyst for
Change.
December 9, 2020
Kirkup B. London, England: Crown Copyright; 2020. ISBN 9781528622714.
https://psnet.ahrq.gov/issue/life-and-death-elizabeth-dixon-catalyst-change
Missed diagnosis of a dangerous condition in utero, treatment errors, lack of respons…
-
psnet.ahrq.gov/node/46199/psn-pdf
September 27, 2017 - The development and implementation of checklists in
obstetrics.
September 27, 2017
Medicine S for M-F, Bernstein PS, Combs A, et al. The development and implementation of checklists in
obstetrics. Am J Obstet Gynecol. 2017;217(2):B2-B6. doi:10.1016/j.ajog.2017.05.032.
https://psnet.ahrq.gov/issue/development-and-i…
-
psnet.ahrq.gov/node/34648/psn-pdf
April 21, 2015 - Gaps in the continuity of care and progress on patient
safety.
April 21, 2015
Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ.
2000;320(7237):791-4.
https://psnet.ahrq.gov/issue/gaps-continuity-care-and-progress-patient-safety
This commentary discusses the concept o…