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psnet.ahrq.gov/issue/users-manual-ioms-quality-chasm-report
August 04, 2021 - Commentary
User's manual for the IOM's 'Quality Chasm' report.
Citation Text:
Berwick DM. A user's manual for the IOM's 'Quality Chasm' report. Health Aff (Millwood). 2002;21(3):80-90.
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psnet.ahrq.gov/issue/top-10-list-safe-and-effective-sign-out
April 12, 2019 - Commentary
The top 10 list for a safe and effective sign-out.
Citation Text:
Kemp CD, Bath JM, Berger J, et al. The top 10 list for a safe and effective sign-out. Arch Surg. 2008;143(10):1008-10. doi:10.1001/archsurg.143.10.1008.
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psnet.ahrq.gov/issue/financial-and-human-cost-medical-error-and-how-massachusetts-can-lead-way-patient-safety
April 03, 2019 - Book/Report
The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead the Way on Patient Safety.
Citation Text:
The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead the Way on Patient Safety. Boston, MA: Betsy Lehman Center for Patient Saf…
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psnet.ahrq.gov/issue/interdisciplinary-collaboration-maintain-culture-safety-labor-and-delivery-setting
January 02, 2017 - Commentary
Interdisciplinary collaboration to maintain a culture of safety in a labor and delivery setting.
Citation Text:
Burke C, Grobman WA, Miller D. Interdisciplinary collaboration to maintain a culture of safety in a labor and delivery setting. J Perinat Neonatal Nurs. 2013;27(2):…
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psnet.ahrq.gov/issue/system-errors-intrapartum-electronic-fetal-monitoring-case-review
May 16, 2012 - Commentary
System errors in intrapartum electronic fetal monitoring: a case review.
Citation Text:
Miller L. System errors in intrapartum electronic fetal monitoring: a case review. J Midwifery Womens Health. 2005;50(6):507-16.
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psnet.ahrq.gov/issue/resilience-and-resilience-engineering-health-care
September 19, 2013 - Commentary
Resilience and resilience engineering in health care.
Citation Text:
Fairbanks RJ, Wears RL, Woods DD, et al. Resilience and resilience engineering in health care. Jt Comm J Qual Patient Saf. 2014;40(8):376-383.
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psnet.ahrq.gov/issue/safety-culture-nursing-homes-opinions-top-managers
June 02, 2010 - Study
Safety culture of nursing homes: opinions of top managers.
Citation Text:
Castle NG, Wagner LM, Ferguson JC, et al. Safety culture of nursing homes: opinions of top managers. Health Care Manage Rev. 2011;36(2):175-187. doi:10.1097/HMR.0b013e3182080d5f.
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psnet.ahrq.gov/issue/reportable-incidents
November 02, 2016 - Newspaper/Magazine Article
Reportable incidents.
Citation Text:
Barishansky RM, Glick DE. Reportable incidents. Establishing policies and procedures for when calls go wrong. EMS magazine. 2009;38(3):43-7.
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psnet.ahrq.gov/issue/state-sepsis-mandates-new-era-regulation-hospital-quality
October 02, 2019 - Commentary
State sepsis mandates—a new era for regulation of hospital quality.
Citation Text:
Hershey TB, Kahn JM. State Sepsis Mandates - A New Era for Regulation of Hospital Quality. N Engl J Med. 2017;376(24):2311-2313. doi:10.1056/NEJMp1611928.
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psnet.ahrq.gov/issue/committed-safety-ten-case-studies-reducing-harm-patients
July 31, 2012 - Book/Report
Committed to Safety: Ten Case Studies on Reducing Harm to Patients.
Citation Text:
Committed to Safety: Ten Case Studies on Reducing Harm to Patients. McCarthy D, Blumenthal D. New York, NY: Commonwealth Fund; 2006.
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psnet.ahrq.gov/issue/addressing-delays-medication-administration-patients-transferred-hospital-nursing-home-pilot
November 16, 2022 - Study
Addressing delays in medication administration for patients transferred from the hospital to the nursing home: a pilot quality improvement project.
Citation Text:
Ward KT, Bates-Jensen B, Eslami MS, et al. Addressing delays in medication administration for patients transferred …
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psnet.ahrq.gov/issue/practices-prevent-venous-thromboembolism-brief-review
June 21, 2016 - Review
Practices to prevent venous thromboembolism: a brief review.
Citation Text:
Lau BD, Haut ER. Practices to prevent venous thromboembolism: a brief review. BMJ Qual Saf. 2014;23(3):187-95. doi:10.1136/bmjqs-2012-001782.
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psnet.ahrq.gov/issue/managing-acute-adverse-event-radiology-department
June 14, 2011 - Commentary
Managing an acute adverse event in a radiology department.
Citation Text:
Kruskal JB, Siewert B, Anderson SW, et al. Managing an acute adverse event in a radiology department. Radiographics. 2008;28(5):1237-50. doi:10.1148/rg.285085064.
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psnet.ahrq.gov/issue/anatomy-and-pathophysiology-errors-occurring-clinical-radiology-practice
February 01, 2011 - Commentary
Anatomy and pathophysiology of errors occurring in clinical radiology practice.
Citation Text:
Brook OR, O'Connell AM, Thornton E, et al. Quality initiatives: anatomy and pathophysiology of errors occurring in clinical radiology practice. Radiographics. 2010;30(5):1401-10. d…
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psnet.ahrq.gov/issue/empowering-patient-safety-outreach-through-interprofessional-partnerships-educating-our
August 17, 2022 - Commentary
Empowering patient safety outreach through interprofessional partnerships: educating our communities.
Citation Text:
Walton L, Childs C, Egeland M, et al. Empowering Patient Safety Outreach Through Interprofessional Partnerships: Educating Our Communities. J Hosp Librariansh. …
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psnet.ahrq.gov/issue/annotated-bibliography-understanding-ambulatory-care-practices-context-patient-safety-and
March 02, 2010 - Commentary
Annotated bibliography: an update to: "Understanding ambulatory care practices in the context of patient safety and quality improvement."
Citation Text:
Kumar PR, Nash DB. Annotated Bibliography: An Update to “Understanding Ambulatory Care Practices in the Context of Patient S…
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psnet.ahrq.gov/issue/health-care-provider-use-private-sector-internal-error-reporting-systems
May 29, 2019 - Study
Health care provider use of private sector internal error-reporting systems.
Citation Text:
Roumm AR, Sciamanna CN, Nash DB. Health care provider use of private sector internal error-reporting systems. Am J Med Qual. 2005;20(6):304-12.
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psnet.ahrq.gov/issue/how-effective-are-incident-reporting-systems-improving-patient-safety-systematic-literature
January 18, 2023 - Review
How effective are incident-reporting systems for improving patient safety? A systematic literature review.
Citation Text:
How effective are incident-reporting systems for improving patient safety? A systematic literature review. Stavropoulou C, Doherty C, Tosey P. Milbank Q. 2015;…
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psnet.ahrq.gov/issue/progress-patient-safety-glass-fuller-it-seems
March 13, 2013 - Commentary
Progress in patient safety: a glass fuller than it seems.
Citation Text:
Pronovost P, Wachter R. Progress in patient safety: a glass fuller than it seems. Am J Med Qual. 2014;29(2):165-9. doi:10.1177/1062860613495554.
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psnet.ahrq.gov/issue/medical-trainees-formal-and-informal-incident-reporting-across-five-hospital-academic-medical
May 10, 2016 - Study
Medical trainees' formal and informal incident reporting across a five-hospital academic medical center.
Citation Text:
Logio LS, Ramanujam R. Medical trainees' formal and informal incident reporting across a five-hospital academic medical center. Jt Comm J Qual Patient Saf. 2010;3…