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psnet.ahrq.gov/issue/elopement-evidence-based-mitigation-and-management
October 19, 2022 - Study
Elopement: evidence-based mitigation and management.
Citation Text:
Marlett JE, Vacovsky BA, Krug EA, et al. Elopement: evidence‐based mitigation and management. Worldviews Evid Based Nurs. 2024;20(6):634-641. doi:10.1111/wvn.12683.
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psnet.ahrq.gov/issue/hospital-admissions-due-adverse-drug-reactions-report-boston-collaborative-drug-surveillance
March 01, 2023 - Study
Classic
Hospital admissions due to adverse drug reactions: a report from the Boston Collaborative Drug Surveillance Program.
Citation Text:
Miller RR. Hospital admissions due to adverse drug reactions. A report from the Boston Collaborative Drug Surveill…
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psnet.ahrq.gov/issue/operating-management-system-high-reliability-leadership-accountability-learning-and
July 01, 2016 - Commentary
Operating management system for high reliability: leadership, accountability, learning and innovation in healthcare.
Citation Text:
Day RM, Demski RJ, Pronovost PJ, et al. Operating management system for high reliability: Leadership, accountability, learning and innovation in …
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psnet.ahrq.gov/issue/framework-operationalizing-risk-practical-approach-patient-safety
October 13, 2018 - Commentary
A framework for operationalizing risk: a practical approach to patient safety.
Citation Text:
Mathews SC, Sutcliffe K, Garrett MR, et al. A framework for operationalizing risk: A practical approach to patient safety. J Healthc Risk Manag. 2018;38(1):38-46. doi:10.1002/jhrm.21…
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psnet.ahrq.gov/issue/johns-hopkins-hospital-identifying-and-addressing-risks-and-safety-issues
January 06, 2017 - Commentary
The Johns Hopkins Hospital: identifying and addressing risks and safety issues.
Citation Text:
Paine LA, Baker DR, Rosenstein BJ, et al. The Johns Hopkins Hospital: identifying and addressing risks and safety issues. Jt Comm J Qual Saf. 2004;30(10):543-50.
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psnet.ahrq.gov/issue/incidence-and-cost-adverse-events-victorian-hospitals-2003-04
July 13, 2010 - Study
The incidence and cost of adverse events in Victorian hospitals 2003-04.
Citation Text:
Ehsani JP, Jackson T, Duckett SJ. The incidence and cost of adverse events in Victorian hospitals 2003-04. Med J Aust. 2006;184(11):551-5.
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psnet.ahrq.gov/issue/use-cascading-a3s-drive-systemwide-improvement
January 29, 2015 - Commentary
Use of cascading A3s to drive systemwide improvement.
Citation Text:
Winner LE, Burroughs TJ, Cady-Reh JA, et al. Use of Cascading A3s to Drive Systemwide Improvement. Jt Comm J Qual Patient Saf. 2017;43(8):422-428. doi:10.1016/j.jcjq.2017.03.011.
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psnet.ahrq.gov/issue/slow-progress-meeting-hospital-safety-standards-learning-leapfrog-groups-efforts
May 13, 2020 - Government Resource
Slow progress on meeting hospital safety standards: learning from the Leapfrog Group's efforts.
Citation Text:
Moran J, Scanlon D. Slow progress on meeting hospital safety standards: learning from the Leapfrog Group's efforts. Health Aff (Millwood). 2013;32(1):27-35…
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psnet.ahrq.gov/node/33716/psn-pdf
September 01, 2011 - KS: Sometimes it is worth the investment up front of somebody who's knowledgeable reviewing the
incident
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psnet.ahrq.gov/issue/patient-safety-reporting-qualitative-study-thoughts-and-perceptions-experts-15-years-after
June 16, 2021 - Study
Patient safety reporting: a qualitative study of thoughts and perceptions of experts 15 years after 'To Err is Human.'
Citation Text:
Mitchell I, Schuster A, Smith K, et al. Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after…
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psnet.ahrq.gov/node/33783/psn-pdf
April 01, 2015 - There needs to be a substantial upfront
investment.
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psnet.ahrq.gov/issue/quality-improvement-ambulatory-surgery-centers-major-national-effort-aimed-reducing
September 23, 2020 - Study
Quality improvement in ambulatory surgery centers: a major national effort aimed at reducing infections and other surgical complications.
Citation Text:
Davis KK, Mahishi V, Singal R, et al. Quality Improvement in Ambulatory Surgery Centers: A Major National Effort Aimed at Reducin…
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psnet.ahrq.gov/issue/quality-improvement-initiative-using-peer-audit-and-feedback-improve-compliance-surgical
March 24, 2021 - Study
A quality improvement initiative using peer audit and feedback to improve compliance with the surgical safety checklist.
Citation Text:
Fridrich A, Imhof A, Staender S, et al. A quality improvement initiative using peer audit and feedback to improve compliance. Int J Qual Health C…
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psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
November 21, 2018 - drive historically high health care construction for the foreseeable future.( 21 ) With each facility investment … The expected growth of health care construction investments over the next 5 years presents a singular
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psnet.ahrq.gov/perspective/conversation-lucian-leape-md
June 12, 2019 - There needs to be a substantial upfront investment.
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psnet.ahrq.gov/issue/i-am-not-doctor-you-physicians-attitudes-about-caring-people-disabilities
February 10, 2015 - Study
‘I am not the doctor for you’: physicians’ attitudes about caring for people with disabilities.
Citation Text:
Lagu T, Haywood C, Reimold KE, et al. ‘I am not the doctor for you’: physicians’ attitudes about caring for people with disabilities. Health Aff (Millwood). 2022;41(10):13…
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psnet.ahrq.gov/issue/model-departmental-quality-management-infrastructure-within-academic-health-system
August 08, 2018 - Commentary
A model for the departmental quality management infrastructure within an academic health system.
Citation Text:
Mathews SC, Demski R, Hooper JE, et al. A Model for the Departmental Quality Management Infrastructure Within an Academic Health System. Acad Med. 2017;92(5):608-613…
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psnet.ahrq.gov/issue/creating-pediatric-joint-council-promote-patient-safety-and-quality-governance-and
January 29, 2015 - Commentary
Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine.
Citation Text:
Rosen MA, Mueller BU, Milstone AM, et al. Creating a Pediatric Joint Council to Promote Patient Safety and Quality, Governance…
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psnet.ahrq.gov/issue/physician-motivation-listening-what-pay-performance-programs-and-quality-improvement
January 02, 2017 - Commentary
Physician motivation: listening to what pay-for-performance programs and quality improvement collaboratives are telling us.
Citation Text:
Herzer KR, Pronovost P. Physician Motivation: Listening to What Pay-for-Performance Programs and Quality Improvement Collaboratives Are Te…
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psnet.ahrq.gov/issue/people-are-more-error-prone-after-committing-error
June 29, 2011 - Study
People are more error-prone after committing an error.
Citation Text:
Adkins TJ, Zhang H, Lee TG. People are more error-prone after committing an error. Nat Commun. 2024;15(1):6422. doi:10.1038/s41467-024-50547-y.
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