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  1. Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events. | PSNet

    psnet.ahrq.gov/issue/indian-health-service-actions-needed-improve-use-data-adverse-events
    September 07, 2016 - Book/Report Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events. Citation Text: Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events. Washington, DC: United States Government Accounting Office; July 10, 2023.  Publication GAO-23-1…

  2. Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. | PSNet

    psnet.ahrq.gov/issue/wake-safe-and-root-cause-analysis-quality-improvement-pediatric-anesthesia
    February 03, 2021 - Commentary Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. Citation Text: Tjia I, Rampersad S, Varughese AM, et al. Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. Anesth Analg. 2014;119(1):122-136. doi:10.1213/ANE.000…

  3. A statewide voluntary patient safety initiative: the Georgia experience. | PSNet

    psnet.ahrq.gov/issue/statewide-voluntary-patient-safety-initiative-georgia-experience
    October 04, 2011 - Commentary A statewide voluntary patient safety initiative: the Georgia experience. Citation Text: Rask KJ, Schuessler LD, Naylor DV. A statewide voluntary patient safety initiative: the Georgia experiene. Jt Comm J Qual Patient Saf. 2006;32(10):564-72. Copy Citation Format: …

  4. Influence of house-staff experience on teaching-hospital mortality: the "July Phenomenon" revisited. | PSNet

    psnet.ahrq.gov/issue/influence-house-staff-experience-teaching-hospital-mortality-july-phenomenon-revisited
    March 04, 2015 - Study Influence of house-staff experience on teaching-hospital mortality: the "July Phenomenon" revisited. Citation Text: van Walraven C, Jennings A, Wong J, et al. Influence of house-staff experience on teaching-hospital mortality: the "July phenomenon" revisited. J Hosp Med. 2011;6(7…

  5. Measurement of ambulatory medication errors in children: a scoping review. | PSNet

    psnet.ahrq.gov/issue/measurement-ambulatory-medication-errors-children-scoping-review
    February 07, 2024 - Review Measurement of ambulatory medication errors in children: a scoping review. Citation Text: Rickey L, Auger K, Britto MT, et al. Measurement of ambulatory medication errors in children: a scoping review. Pediatrics. 2023;152(6):e2023061281. doi:10.1542/peds.2023-061281. Copy Citat…

  6. Costs and consequences associated with misdiagnosed lower extremity cellulitis. | PSNet

    psnet.ahrq.gov/issue/costs-and-consequences-associated-misdiagnosed-lower-extremity-cellulitis
    November 12, 2014 - Study Costs and consequences associated with misdiagnosed lower extremity cellulitis. Citation Text: Weng QY, Raff AB, Cohen JM, et al. Costs and Consequences Associated With Misdiagnosed Lower Extremity Cellulitis. JAMA Dermatol. 2016;153(2). doi:10.1001/jamadermatol.2016.3816. Copy C…

  7. Managing clinical failure: a complex adaptive system perspective. | PSNet

    psnet.ahrq.gov/issue/managing-clinical-failure-complex-adaptive-system-perspective
    August 13, 2014 - Study Managing clinical failure: a complex adaptive system perspective. Citation Text: Matthews JI, Thomas PT. Managing clinical failure: a complex adaptive system perspective. Int J Health Care Qual Assur. 2007;20(3):184-194. doi:10.1108/09526860710743336. Copy Citation Format: …

  8. Creating a Health Information Exchange Application to Provide Fast Access to Patient Data in Emergency Department Settings | Digital Healthcare Research

    digital.ahrq.gov/2020-year-review/research-summary/creating-health-information-exchange-application-provide-fast-access-patient-data-emergency
    January 01, 2020 - Creating a Health Information Exchange Application to Provide Fast Access to Patient Data in Emergency Department Settings Integrating health information exchange (HIE) data directly into electronic health records has the potential to improve delivery of care and patient outcomes, as well as increase clinician sati…

  9. Using an automated risk assessment report to identify patients at risk for clinical deterioration. | PSNet

    psnet.ahrq.gov/issue/using-automated-risk-assessment-report-identify-patients-risk-clinical-deterioration
    February 15, 2017 - Commentary Using an automated risk assessment report to identify patients at risk for clinical deterioration. Citation Text: Whittington J, White R, Haig KM, et al. Using an automated risk assessment report to identify patients at risk for clinical deterioration. Jt Comm J Qual Patient S…

  10. How policy makers can smooth the way for communication-and-resolution programs. | PSNet

    psnet.ahrq.gov/issue/how-policy-makers-can-smooth-way-communication-and-resolution-programs
    December 19, 2018 - Commentary How policy makers can smooth the way for communication-and-resolution programs. Citation Text: Sage WM, Gallagher TH, Armstrong S, et al. How policy makers can smooth the way for communication-and- resolution programs. Health Aff (Millwood). 2014;33(1):11-9. doi:10.1377/hlthaf…

  11. Patient safety: a consumer's perspective. | PSNet

    psnet.ahrq.gov/issue/patient-safety-consumers-perspective
    January 12, 2022 - Study Patient safety: a consumer's perspective. Citation Text: Hovey RB, Dvorak ML, Burton T, et al. Patient safety: a consumer's perspective. Qual Health Res. 2011;21(5):662-72. doi:10.1177/1049732311399779. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3…

  12. The debrief imperative: building teaming competencies and team effectiveness. | PSNet

    psnet.ahrq.gov/issue/debrief-imperative-building-teaming-competencies-and-team-effectiveness
    December 16, 2020 - Commentary The debrief imperative: building teaming competencies and team effectiveness. Citation Text: Tannenbaum SI, Greilich PE. The debrief imperative: building teaming competencies and team effectiveness. BMJ Qual Saf. 2023;32(3):125-128. doi:10.1136/bmjqs-2022-015259. Copy Citati…

  13. Burnout Among Health Care Professionals. A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care. | PSNet

    psnet.ahrq.gov/issue/burnout-among-health-care-professionals-call-explore-and-address-underrecognized-threat-safe
    November 11, 2020 - Book/Report Burnout Among Health Care Professionals. A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care. Citation Text: Burnout Among Health Care Professionals. A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care. Dyrbye …

  14. Adverse events in hospitals: the patient's point of view. | PSNet

    psnet.ahrq.gov/issue/adverse-events-hospitals-patients-point-view
    December 29, 2014 - Review Adverse events in hospitals: the patient's point of view. Citation Text: Guijarro M, Andrés JMA, Mira JJ, et al. Adverse events in hospitals: the patient's point of view. Qual Saf Health Care. 2010;19(2):144-7. doi:10.1136/qshc.2007.025585. Copy Citation Format: DO…

  15. Diseases of medical progress. | PSNet

    psnet.ahrq.gov/issue/diseases-medical-progress
    June 27, 2018 - Review Classic Diseases of medical progress. Citation Text: MOSER RH. Diseases of medical progress. N Engl J Med. 1956;255(13):606-14. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  16. Error in medicine. | PSNet

    psnet.ahrq.gov/issue/error-medicine
    November 02, 2014 - Commentary Classic Error in medicine. Citation Text: Leape L. Error in medicine. JAMA. 1994;272(23):1851-1857. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation …

  17. Clinical Summary: Screening for HIV Infection (pdf file)

    www.uspreventiveservicestaskforce.org/home/getfilebytoken/WJE2r5v4CHc9dMZ4GT7dnT
    Clinical Summary: Screening for HIV Infection Clinical Summary: Screening for HIV Infection Population Adolescents and adults aged 15 to 65 years Pregnant Persons Recommendation Screen for HIV infection. Grade: A Screen for HIV infection. Grade: A Risk Assessment Although all adolesc…

  18. The interrelationship of isolation precautions and adverse events in an acute care facility. | PSNet

    psnet.ahrq.gov/issue/interrelationship-isolation-precautions-and-adverse-events-acute-care-facility
    September 24, 2010 - Study The interrelationship of isolation precautions and adverse events in an acute care facility. Citation Text: Spence MR, McQuaid M. The interrelationship of isolation precautions and adverse events in an acute care facility. Am J Infect Control. 2011;39(2):154-155. doi:10.1016/j.aj…

  19. Failure mode and effects analysis: too little for too much? | PSNet

    psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-too-little-too-much
    November 25, 2009 - Commentary Failure mode and effects analysis: too little for too much? Citation Text: Franklin BD, Shebl NA, Barber N. Failure mode and effects analysis: too little for too much? BMJ Qual Saf. 2012;21(7):607-11. doi:10.1136/bmjqs-2011-000723. Copy Citation Format: DOI Goo…

  20. Amid lack of accountability for bias in maternity care, a California family seeks justice. | PSNet

    psnet.ahrq.gov/issue/amid-lack-accountability-bias-maternity-care-california-family-seeks-justice
    September 06, 2023 - Newspaper/Magazine Article Amid lack of accountability for bias in maternity care, a California family seeks justice. Citation Text: Amid lack of accountability for bias in maternity care, a California family seeks justice. Kwon S. KFF Health News. August 8, 2023 Copy Citation …
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