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psnet.ahrq.gov/node/46346/psn-pdf
October 29, 2017 - Root cause analysis of ICU adverse events in the
Veterans Health Administration.
October 29, 2017
Corwin GS, Mills PD, Shanawani H, et al. Root Cause Analysis of ICU Adverse Events in the Veterans
Health Administration. Jt Comm J Qual Patient Saf. 2017;43(11):580-590. doi:10.1016/j.jcjq.2017.04.009.
https://psnet.…
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psnet.ahrq.gov/node/36675/psn-pdf
January 18, 2011 - Target-focused medical emergency team training using a
human patient simulator: effects on behaviour and
attitude.
January 18, 2011
Wallin C-J, Meurling L, Hedman L, et al. Target-focused medical emergency team training using a human
patient simulator: effects on behaviour and attitude. Med Educ. 2007;41(2):173-80…
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www.ahrq.gov/research/findings/final-reports/advisorycouncil/adcouncilack.html
April 01, 2018 - Guide for Developing a Community-Based Patient Safety Advisory Council
Acknowledgments
We are in the midst of an exciting national movement, endorsed by health care entities and patients alike, to engage patients and families as partners with their health care providers. Including patients in the design and i…
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psnet.ahrq.gov/node/47523/psn-pdf
December 05, 2018 - Developing standardized "receiver-driven" handoffs
between referring providers and the emergency
department: results of a multidisciplinary needs
assessment.
December 5, 2018
Huth K, Stack AM, Chi G, et al. Developing Standardized "Receiver-Driven" Handoffs Between Referring
Providers and the Emergency Department…
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psnet.ahrq.gov/node/60892/psn-pdf
September 09, 2020 - Applying thematic synthesis to interpretation and
commentary in epidemiological studies: identifying what
contributes to successful interventions to promote hand
hygiene in patient care.
September 9, 2020
Drey N, Gould D, Purssell E, et al. Applying thematic synthesis to interpretation and commentary in
epidemiol…
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psnet.ahrq.gov/node/47592/psn-pdf
July 17, 2019 - Identifying potential medication discrepancies during
medication reconciliation in the post-acute long-term care
setting.
July 17, 2019
Cook H, Parson J, Brandt N. Identifying Potential Medication Discrepancies During Medication
Reconciliation in the Post-Acute Long-Term Care Setting. J Gerontol Nurs. 2019;45(7):5…
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psnet.ahrq.gov/node/35328/psn-pdf
May 19, 2015 - Applicability of Healthcare Failure Mode and Effects
Analysis to healthcare epidemiology: evaluation of the
sterilization and use of surgical instruments.
May 19, 2015
Weinstein RA, Linkin DR, Sausman C, et al. Applicability of Healthcare Failure Mode and Effects Analysis
to Healthcare Epidemiology: Evaluation of …
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psnet.ahrq.gov/node/845348/psn-pdf
February 02, 2012 - Liquid-based Papanicolaou tests in endometrial
carcinoma diagnosis: performance, error root cause
analysis, and quality improvement.
February 2, 2012
Sams SB, Currens HS, Raab SS. Liquid-based Papanicolaou tests in endometrial carcinoma diagnosis:
performance, error root cause analysis, and quality improvement. Am…
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psnet.ahrq.gov/issue/marylanddc-patient-safety-coalition
September 28, 2023 - Multi-use Website
Maryland/DC Patient Safety Coalition.
Save
Save to your library
Print
Download PDF
Share
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March 17, 2011
The Maryland Patient Safety Center facilitates the study …
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psnet.ahrq.gov/node/47187/psn-pdf
September 05, 2018 - Supporting clinicians after adverse events: development
of a clinician peer support program.
September 5, 2018
Lane MA, Newman BM, Taylor MZ, et al. Supporting Clinicians After Adverse Events: Development of a
Clinician Peer Support Program. J Patient Saf. 2018;14(3):e56-e60. doi:10.1097/PTS.0000000000000508.
http…
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psnet.ahrq.gov/node/839827/psn-pdf
December 20, 2020 - Racial bias in pulse oximetry measurement.
December 20, 2020
Sjoding MW, Dickson RP, Iwashyna TJ, et al. Racial bias in pulse oximetry measurement. N Engl J Med.
2020;383(25):2477-2478. doi:10.1056/nejmc2029240.
https://psnet.ahrq.gov/issue/racial-bias-pulse-oximetry-measurement
Pulse oximetry is used to triage pa…
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psnet.ahrq.gov/node/866525/psn-pdf
August 14, 2024 - Stakeholder perceptions of and attitudes towards
problematic polypharmacy and prescribing cascades: a
qualitative study.
August 14, 2024
Jennings AA, Doherty AS, Clyne B, et al. Stakeholder perceptions of and attitudes towards problematic
polypharmacy and prescribing cascades: a qualitative study. Age Ageing. 2024…
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psnet.ahrq.gov/node/60521/psn-pdf
May 27, 2020 - Assessment of potentially inappropriate prescribing of
opioid analgesics requiring prior opioid tolerance.
May 27, 2020
Jeffery MM, Chaisson CE, Hane C, et al. Assessment of potentially inappropriate prescribing of opioid
analgesics requiring prior opioid tolerance. JAMA Netw Open. 2020;3(4).
doi:10.1001/jamanetwo…
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psnet.ahrq.gov/node/46903/psn-pdf
December 04, 2018 - Salzburg Global Seminar Session 565—Better Health
Care: How Do We Learn About Improvement?
December 4, 2018
Massoud MR, Kimble LE, Goldmann D, eds. Int J Qual Health Care. 2018;30(suppl 1):1-41.
https://psnet.ahrq.gov/issue/salzburg-global-seminar-session-565-better-health-care-how-do-we-learn-
about-improvement
…
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psnet.ahrq.gov/node/41132/psn-pdf
March 13, 2012 - Spreading a medication administration intervention
organizationwide in six hospitals.
March 13, 2012
Kliger J, Singer SJ, Hoffman F, et al. Spreading a medication administration intervention organizationwide
in six hospitals. Jt Comm J Qual Patient Saf. 2012;38(2):51-60.
https://psnet.ahrq.gov/issue/spreading-medi…
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psnet.ahrq.gov/node/41814/psn-pdf
March 04, 2015 - Autopsy as a quality control measure for radiology, and
vice versa.
March 4, 2015
Murken DR, Ding M, Branstetter BF, et al. Autopsy as a quality control measure for radiology, and vice
versa. AJR Am J Roentgenol. 2012;199(2):394-401. doi:10.2214/AJR.11.8386.
https://psnet.ahrq.gov/issue/autopsy-quality-control-mea…
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psnet.ahrq.gov/node/44930/psn-pdf
June 01, 2016 - How well is quality improvement described in the
perioperative care literature? A systematic review.
June 1, 2016
Jones EL, Lees N, Martin G, et al. How Well Is Quality Improvement Described in the Perioperative Care
Literature? A Systematic Review. Jt Comm J Qual Patient Saf. 2016;42(5):196-206.
https://psnet.ahr…
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psnet.ahrq.gov/node/35451/psn-pdf
January 05, 2017 - Closing the loop: follow-up and feedback in a patient
safety program.
January 5, 2017
Gandhi TK, Graydon-Baker E, Huber CN, et al. Closing the loop: follow-up and feedback in a patient safety
program. Jt Comm J Qual Patient Saf. 2005;31(11):614-21.
https://psnet.ahrq.gov/issue/closing-loop-follow-and-feedback-pati…
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psnet.ahrq.gov/node/37487/psn-pdf
May 26, 2011 - Predicting computerized physician order entry system
adoption in US hospitals: can the federal mandate be
met?
May 26, 2011
Ford EW, McAlearney AS, Phillips MT, et al. Predicting computerized physician order entry system
adoption in US hospitals: Can the federal mandate be met? Int J Med Inform. 2007;77(8).
doi:1…
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psnet.ahrq.gov/node/45014/psn-pdf
July 18, 2016 - Improving patient safety through simulation training in
anesthesiology: where are we?
July 18, 2016
Green M, Tariq R, Green P. Improving Patient Safety through Simulation Training in Anesthesiology:
Where Are We? Anesthesiol Res Pract. 2016;2016:4237523. doi:10.1155/2016/4237523.
https://psnet.ahrq.gov/issue/impro…