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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845651/psn-pdf
    November 17, 2016 - Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. November 17, 2016 Herzog R, Elgort DR, Flanders AE, et al. Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patien…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39197/psn-pdf
    January 06, 2010 - Resident fatigue: is there a patient safety issue? January 6, 2010 Mitchell CD, Mooty CR, Dunn EL, et al. Resident fatigue: is there a patient safety issue? Am J Surg. 2009;198(6):811-6. doi:10.1016/j.amjsurg.2009.04.028. https://psnet.ahrq.gov/issue/resident-fatigue-there-patient-safety-issue Regulations limiting…

  3. HHCEB Presentation (ppt file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/umich-slides.ppt
    May 20, 2012 - HHCEB Presentation * VTE Prevention: An Institution-wide Initiative University of Michigan Caprini VTE risk assessment May 20, 2012 Marc Moote, PA-C Chief Physician Assistant University of Michigan Health System * * Key Strategies Scope: ALL adult inpatients Standardized VTE Protocol – Caprini model Mandato…

  4. A. T. Still University, School of Osteopathic Medicine in Arizona PBRN | Agency for Healthcare Research and Quality

    www.ahrq.gov/ncepcr/communities/pbrn/registry/t-still-university-school-osteopathic-medicine-arizona-pbrn.html
    January 01, 2012 - A. T. Still University, School of Osteopathic Medicine in Arizona PBRN Status: Active Registered Date: January 1, 2012 PBRN Acronym: ATSU SOMA PBRN PBRN Type: Mixed Network (a combination of family medicine, internal medicine, pediatrics, nursing and/or other specialties) Net…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842763/psn-pdf
    January 18, 2023 - Implementation of peer messengers to deliver feedback: an observational study to promote professionalism in nursing. January 18, 2023 Baldwin CA, Hanrahan K, Edmonds SW, et al. Implementation of peer messengers to deliver feedback: an observational study to promote professionalism in nursing. Jt Comm J Qual Patien…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36003/psn-pdf
    March 28, 2011 - The "To Err Is Human Report" and the patient safety literature. March 28, 2011 Stelfox HT, Palmisani S, Scurlock C, et al. The "To Err is Human" report and the patient safety literature. Qual Saf Health Care. 2006;15(3):174-8. https://psnet.ahrq.gov/issue/err-human-report-and-patient-safety-literature This study …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35436/psn-pdf
    September 15, 2009 - Hospital nurse staffing and patient mortality, emotional exhaustion, and job dissatisfaction. September 15, 2009 Halm M, Peterson M, Kandels M, et al. Hospital nurse staffing and patient mortality, emotional exhaustion, and job dissatisfaction. Clin Nurse Spec. 2005;19(5):241-254. https://psnet.ahrq.gov/issue/hosp…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40119/psn-pdf
    January 05, 2011 - Effects of learning climate and registered nurse staffing on medication errors. January 5, 2011 Chang YK, Mark BA. Effects of Learning Climate and Registered Nurse Staffing on Medication Errors. Nurs Res. 2010;60(1). doi:10.1097/nnr.0b013e3181ff73cc. https://psnet.ahrq.gov/issue/effects-learning-climate-and-regist…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841141/psn-pdf
    December 07, 2022 - Urgent referrals from primary care to dermatology for lesions suspicious for skin cancer: patterns, outcomes, and need for systems improvement. December 7, 2022 Pagani K, Lukac D, Olbricht SM, et al. Urgent referrals from primary care to dermatology for lesions suspicious for skin cancer: patterns, outcomes, and n…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44552/psn-pdf
    June 21, 2016 - Reducing diagnostic errors—why now? June 21, 2016 Khullar D, Jha AK, Jena AB. Reducing diagnostic errors--why now? N Engl J Med. 2015;373(26):2491- 2493. doi:10.1056/NEJMp1508044. https://psnet.ahrq.gov/issue/reducing-diagnostic-errors-why-now Diagnostic error has recently garnered attention as a patient safety pr…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37871/psn-pdf
    January 06, 2017 - A controlled trial of a rapid response system in an academic medical center. January 6, 2017 Rothschild JM, Woolf S, Finn KM, et al. A controlled trial of a rapid response system in an academic medical center. Jt Comm J Qual Patient Saf. 2008;34(7):417-25, 365. https://psnet.ahrq.gov/issue/controlled-trial-rapid-r…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844769/psn-pdf
    January 01, 2020 - Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot? September 18, 2019 Ellis RJ, Schlick CJR, Feinglass J, et al. Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot? BMJ Qual Saf. 2020;29(2):103-112. doi:10.1136/…

  13. Story Guides – Making Comparative Effectiveness Useful for Vulnerable Patients (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/iadapt/allison.pdf
    December 19, 2014 - Story Guides – Making Comparative Effectiveness Useful for Vulnerable Patients Research to …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37324/psn-pdf
    February 16, 2011 - A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. February 16, 2011 Hickson GB, Pichert JW, Webb LE, et al. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Acad Med. 2007;82…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60623/psn-pdf
    June 24, 2020 - Communication with health care workers regarding health care-associated exposure to coronavirus 2019: a checklist to facilitate disclosure. June 24, 2020 Wickner PG, Hartley T, Salmasian H, et al. Communication with health care workers regarding health care- associated exposure to coronavirus 2019: a checklist to …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40859/psn-pdf
    October 19, 2011 - Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations. October 19, 2011 Staggers N, Clark L, Blaz JW, et al. Why patient summaries in electronic health records do not provide th…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37480/psn-pdf
    January 23, 2008 - Lost opportunities: how physicians communicate about medical errors. January 23, 2008 Garbutt J, Waterman AD, Kapp JM, et al. Lost Opportunities: How Physicians Communicate About Medical Errors. Health Aff (Millwood). 2008;27(1):246-255. doi:10.1377/hlthaff.27.1.246. https://psnet.ahrq.gov/issue/lost-opportunities…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36457/psn-pdf
    May 27, 2011 - Controversies surrounding use of order sets for clinical decision support in computerized provider order entry. May 27, 2011 Bobb AM, Payne TH, Gross PA. Viewpoint: controversies surrounding use of order sets for clinical decision support in computerized provider order entry. J Am Med Inform Assoc. 2007;14(1):41-7.…

  19. Action Planning for the SOPS Surveys-Overview (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/02-brady-sops-action-planning-tool.pdf
    June 02, 2025 - Action Planning for the SOPS Surveys-Overview 6 Overview of AHRQ’s Patient Safety Priorities Jeff Brady, MD, MPH Director, Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality (AHRQ) Rear Admiral, Assistant Surgeon General, U.S. Public Health Service AHRQ’s Core Compet…

  20. New Ideas Lead to Big Changes in Care | Agency for Healthcare Research and Quality

    www.ahrq.gov/evidencenow/projects/heart-health/about/stories/in-action/cascades-east.html
    March 01, 2021 - New Ideas Lead to Big Changes in Care Like many small- and medium-sized practices, the team at Cascades East Family Medicine is always searching for ways to improve care. For Cascades East, this meant enrolling in EvidenceNOW, which connected them with a practice facilitator, Mr. Steven Brantley. In their wor…
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