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psnet.ahrq.gov/issue/teamwork-and-teamwork-training-healthcare
March 02, 2022 - Special or Theme Issue
Teamwork and Teamwork Training in Healthcare.
Citation Text:
Teamwork and Teamwork Training in Health care: An Integration and a Path Forward. Buljac-Samardzic M, Dekker-van Doorn C, Maynard MT, eds. Group Org Manag. 2018;43(3):351-527. doi:10.1177/105960111877466…
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psnet.ahrq.gov/issue/view-world-through-different-lens-shadowing-another-provider
January 22, 2017 - Commentary
View the world through a different lens: shadowing another provider.
Citation Text:
Thompson DA, Holzmueller CG, Lubomski LH, et al. View the world through a different lens: shadowing another provider. Jt Comm J Qual Patient Saf. 2008;34(10):614-8, 561.
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psnet.ahrq.gov/issue/impact-organizations-healthcare-associated-infections
December 11, 2024 - Commentary
Impact of organizations on healthcare-associated infections.
Citation Text:
Castro-Sánchez E, Holmes AH. Impact of organizations on healthcare-associated infections. J Hosp Infect. 2015;89(4):346-50. doi:10.1016/j.jhin.2015.01.012.
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DOI Googl…
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psnet.ahrq.gov/issue/human-factors-engineering-patient-safety
September 13, 2017 - Commentary
Human factors engineering in patient safety.
Citation Text:
Weinger MB, Gaba DM. Human factors engineering in patient safety. Anesthesiology. 2014;120(4):801-6. doi:10.1097/ALN.0000000000000144.
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psnet.ahrq.gov/issue/implementing-aorn-recommended-practices-transfer-patient-care-information
October 07, 2013 - Commentary
Implementing AORN recommended practices for transfer of patient care information.
Citation Text:
Seifert PC. Implementing AORN recommended practices for transfer of patient care information. AORN J. 2012;96(5):475-93. doi:10.1016/j.aorn.2012.08.011.
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Forma…
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psnet.ahrq.gov/issue/shifting-learning-curve
March 09, 2009 - Commentary
Shifting the learning curve.
Citation Text:
Reynolds T, Kong M-L. Shifting the learning curve. BMJ. 2010;341:c6260. doi:10.1136/bmj.c6260.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/issue/swiss-cheese-model-adverse-event-occurrence-closing-holes
September 25, 2024 - Commentary
The Swiss cheese model of adverse event occurrence—closing the holes.
Citation Text:
Stein JE, Heiss K. The Swiss cheese model of adverse event occurrence--Closing the holes. Semin Pediatr Surg. 2015;24(6):278-82. doi:10.1053/j.sempedsurg.2015.08.003.
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psnet.ahrq.gov/issue/patient-safety-institute-demonstration-project-model-implementing-local-health-information
May 15, 2013 - Commentary
The Patient Safety Institute demonstration project: a model for implementing a local health information infrastructure.
Citation Text:
Classen D, Kanhouwa M, Will D, et al. The patient safety institute demonstration project: a model for implementing a local health informatio…
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psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
February 26, 2025 - Health Systems for Patient Safety
February 26, 2025
Patient Safety Innovations
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psnet.ahrq.gov/web-mm/discharged-blindly
October 26, 2022 - View More
Related Resources
Patient Safety Innovations
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - However, all of these innovations create more opportunities for error, unless they are accompanied by
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psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors
April 01, 2008 - Primers
Falls
June 15, 2024
Patient Safety Innovations
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psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - • Innovations in afferent & efferent limb structures show promise for
increased benefit. … Elective Spine Surgery: Failure to Rescue after Limited
Response to Nursing Concerns [CME/MOC]
• Innovations
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psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
January 27, 2021 - Organization-wide adoption of computerized provider order entry systems: a study based on diffusion of innovations … ECG Oversight in Cardiac Surgery
April 24, 2024
Patient Safety Innovations
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - These innovations include a 3D matrix/
barcode label-based sponge counting system, a radiofrequency … Site-specific usability analyses and comparative effectiveness studies of new innovations and
technological
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psnet.ahrq.gov/node/49570/psn-pdf
October 01, 2008 - Recurrent Hypoglycemia: A Care Transition Failure?
October 1, 2008
Eytan T. Recurrent Hypoglycemia: A Care Transition Failure? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
Case Objectives
Understand the complementary abilities of an electronic health record a…
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psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - View More
Related Resources
Patient Safety Innovations … Counterpoint, and Areas of Agreement
September 24, 2024
Patient Safety Innovations
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psnet.ahrq.gov/node/33699/psn-pdf
August 01, 2010 - They are also the site of most clinical education, significant amounts of
research, and substantial innovations
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psnet.ahrq.gov/training-catalog
June 01, 2025 - Organization:
The Research Gate (TRG)
Event Description: Innovations
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.128_slideshow.ppt
July 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case July 2006
Moving Pains
Source and Credits
This presentation is based on the June/July 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Hildy Schell, RN, MS, CCRN, CCNS, and…