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  1. New U.S. health crisis looms as patients without COVID-19 delay care. | PSNet

    psnet.ahrq.gov/issue/new-us-health-crisis-looms-patients-without-covid-19-delay-care
    July 29, 2020 - Newspaper/Magazine Article New U.S. health crisis looms as patients without COVID-19 delay care. Citation Text: Bernstein S. New U.S. health crisis looms as patients without COVID-19 delay care. Reuters. 2020;July 13. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…

  2. Hospice diagnosis: polypharmacy—a teachable moment. | PSNet

    psnet.ahrq.gov/issue/hospice-diagnosis-polypharmacy-teachable-moment
    April 24, 2018 - Commentary Hospice diagnosis: polypharmacy—a teachable moment. Citation Text: Larson CK, Kao H. Hospice Diagnosis: Polypharmacy: A Teachable Moment. JAMA Intern Med. 2015;175(11):1750-1751. doi:10.1001/jamainternmed.2015.5253. Copy Citation Format: DOI Google Scholar PubMed…

  3. Errors in ABO labeling of deceased donor kidneys: case reports and approach to ensuring patient safety. | PSNet

    psnet.ahrq.gov/issue/errors-abo-labeling-deceased-donor-kidneys-case-reports-and-approach-ensuring-patient-safety
    June 09, 2021 - Study Errors in ABO labeling of deceased donor kidneys: case reports and approach to ensuring patient safety. Citation Text: Friedman AL, Lee KC, Lee GD. Errors in ABO Labeling of Deceased Donor Kidneys: Case Reports and Approach to Ensuring Patient Safety. American Journal of Transpla…

  4. Sharing lessons learned to prevent incorrect surgery. | PSNet

    psnet.ahrq.gov/issue/sharing-lessons-learned-prevent-incorrect-surgery
    July 16, 2015 - Study Sharing lessons learned to prevent incorrect surgery. Citation Text: Neily J, Mills PD, Paull DE, et al. Sharing lessons learned to prevent incorrect surgery. Am Surg. 2012;78(11):1276-1280. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7…

  5. Curriculum development and implementation of a national interprofessional fellowship in patient safety. | PSNet

    psnet.ahrq.gov/issue/curriculum-development-and-implementation-national-interprofessional-fellowship-patient
    November 18, 2016 - Commentary Curriculum development and implementation of a national interprofessional fellowship in patient safety. Citation Text: Watts B, Williams L, Mills PD, et al. Curriculum Development and Implementation of a National Interprofessional Fellowship in Patient Safety. J Patient Saf. 2…

  6. Department of Veterans Affairs Chief Resident in Quality and Patient Safety Program: a model to spread change. | PSNet

    psnet.ahrq.gov/issue/department-veterans-affairs-chief-resident-quality-and-patient-safety-program-model-spread
    September 05, 2018 - Commentary Department of Veterans Affairs Chief Resident in Quality and Patient Safety Program: a model to spread change. Citation Text: Watts B, Paull DE, Williams LC, et al. Department of Veterans Affairs Chief Resident in Quality and Patient Safety Program: A Model to Spread Change. A…

  7. Using electronic health records to identify adverse drug events in ambulatory care: a systematic review. | PSNet

    psnet.ahrq.gov/issue/using-electronic-health-records-identify-adverse-drug-events-ambulatory-care-systematic
    May 04, 2012 - Review Using electronic health records to identify adverse drug events in ambulatory care: a systematic review. Citation Text: Feng C, Le D, McCoy AB. Using Electronic Health Records to Identify Adverse Drug Events in Ambulatory Care: A Systematic Review. Appl Clin Inform. 2019;10(1):123…

  8. Factors associated with unanticipated day of surgery deaths in Department of Veterans Affairs hospitals. | PSNet

    psnet.ahrq.gov/issue/factors-associated-unanticipated-day-surgery-deaths-department-veterans-affairs-hospitals
    July 12, 2010 - Study Factors associated with unanticipated day of surgery deaths in Department of Veterans Affairs hospitals. Citation Text: Bishop MJ, Souders JE, Peterson CM, et al. Factors associated with unanticipated day of surgery deaths in Department of Veterans Affairs hospitals. Anesth Analg…

  9. Patient safety culture in home care: experiences of home-care nurses. | PSNet

    psnet.ahrq.gov/issue/patient-safety-culture-home-care-experiences-home-care-nurses
    July 02, 2008 - Study Patient safety culture in home care: experiences of home-care nurses. Citation Text: Berland A, Holm AL, Gundersen D, et al. Patient safety culture in home care: experiences of home-care nurses. J Nurs Manag. 2012;20(6):794-801. doi:10.1111/j.1365-2834.2012.01461.x. Copy Citati…

  10. Nurses' perceptions of simulation-based interprofessional training program for rapid response and code blue events. | PSNet

    psnet.ahrq.gov/issue/nurses-perceptions-simulation-based-interprofessional-training-program-rapid-response-and
    January 04, 2012 - Study Nurses' perceptions of simulation-based interprofessional training program for rapid response and code blue events. Citation Text: Wehbe-Janek H, Lenzmeier CR, Ogden PE, et al. Nurses' perceptions of simulation-based interprofessional training program for rapid response and code …

  11. Team situation awareness and the anticipation of patient progress during ICU rounds. | PSNet

    psnet.ahrq.gov/issue/team-situation-awareness-and-anticipation-patient-progress-during-icu-rounds
    May 06, 2009 - Study Team situation awareness and the anticipation of patient progress during ICU rounds. Citation Text: Reader TW, Flin R, Mearns K, et al. Team situation awareness and the anticipation of patient progress during ICU rounds. BMJ Qual Saf. 2011;20(12):1035-42. doi:10.1136/bmjqs.2010.0…

  12. Dissecting communication barriers in healthcare: a path to enhancing communication resiliency, reliability, and patient safety. | PSNet

    psnet.ahrq.gov/issue/dissecting-communication-barriers-healthcare-path-enhancing-communication-resiliency
    July 12, 2023 - Commentary Dissecting communication barriers in healthcare: a path to enhancing communication resiliency, reliability, and patient safety. Citation Text: Guttman OT, Lazzara EH, Keebler JR, et al. Dissecting Communication Barriers in Healthcare: A Path to Enhancing Communication Resilien…

  13. Improving diagnostic performance through feedback: the Diagnosis Learning Cycle. | PSNet

    psnet.ahrq.gov/issue/improving-diagnostic-performance-through-feedback-diagnosis-learning-cycle
    December 16, 2020 - Commentary Improving diagnostic performance through feedback: the Diagnosis Learning Cycle. Citation Text: Fernandez Branson C, Williams M, Chan TM, et al. Improving diagnostic performance through feedback: the Diagnosis Learning Cycle. BMJ Qual Saf. 2021;30(12):1002-1009. doi:10.1136/bm…

  14. Systems approach to suicide prevention: strengthening culture, practice, and education. | PSNet

    psnet.ahrq.gov/issue/systems-approach-suicide-prevention-strengthening-culture-practice-and-education
    July 10, 2024 - Commentary Systems approach to suicide prevention: strengthening culture, practice, and education. Citation Text: Pisani AR, Boudreaux ED. Systems approach to suicide prevention: strengthening culture, practice, and education. Focus (Am Psychiatr Publ). 2023;21(2):152-159. doi:10.1176/ap…

  15. Operational measurement of diagnostic safety: state of the science. | PSNet

    psnet.ahrq.gov/issue/operational-measurement-diagnostic-safety-state-science-0
    September 28, 2022 - Commentary Emerging Classic Operational measurement of diagnostic safety: state of the science. Citation Text: Singh H, Bradford A, Goeschel CA. Operational measurement of diagnostic safety: state of the science. Diagnosis (Berl). 2021;8(1):51-66. doi:10.1515/dx…

  16. Dashboards for visual display of patient safety data: a systematic review. | PSNet

    psnet.ahrq.gov/issue/dashboards-visual-display-patient-safety-data-systematic-review
    November 11, 2020 - Review Dashboards for visual display of patient safety data: a systematic review. Citation Text: Murphy DR, Savoy A, Satterly T, et al. Dashboards for visual display of patient safety data: a systematic review. BMJ Health Care Inform. 2021;28(1):e100437. doi:10.1136/bmjhci-2021-100437. …

  17. Towards a framework for managing risk associated with technology-induced error. | PSNet

    psnet.ahrq.gov/issue/towards-framework-managing-risk-associated-technology-induced-error
    May 10, 2013 - Commentary Towards a framework for managing risk associated with technology-induced error. Citation Text: Borycki EM, Kushniruk AW. Towards a Framework for Managing Risk Associated with Technology-Induced Error. Stud Health Technol Inform. 2017;234:42-48. Copy Citation Format: …

  18. An Evidence Review of Active Surveillance in Men with Localized Prostate Cancer (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/prostate-cancer-surveillance_disposition-comments.pdf
    December 01, 2011 - An Evidence Review of Active Surveillance in Men with Localized Prostate Cancer Source: http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and- reports/?productid=859&pageaction=displayproduct Published Online: December 2011 Comparative Effectiveness Research Review Disposition …

  19. Cystic-Fibrosis-Hgh Surveillance (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/cystic-fibrosis-hgh_surveillance.pdf
    August 01, 2012 - CER # 23: Effectiveness of Recombinant Human Growth Hormone (rhGH) in the Treatment of Patients with Cystic Fibrosis Original release date: October 2010 Surveillance Report 1st Assessment: November, 2011 Surveillance Report 2nd Assessment: August 2012 Key Findings 1st Assessment: • All conclusions for KQ…

  20. Putoolssect7 (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressureulcertoolkit/putoolssect7.docx
    February 16, 2011 - Section 7. Tools and Resources 0A: Introductory Executive Summary for Stakeholders 1A: Clinical Staff Attitudes Towards Pressure Ulcer Prevention 1B: Stakeholder Analysis 1C: Leadership Support Assessment 1D: Business Case Form 1E: Resource Needs Assessment 2A: Multidisciplinary Team 2B: Quality Improvement Process 2C…
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