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psnet.ahrq.gov/node/49531/psn-pdf
March 01, 2007 - Failure to Report
March 1, 2007
Spath P. Failure to Report. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/failure-report
Case Objectives
List common causes of medical errors.
Appreciate the magnitude of underreporting of adverse events.
List the common barriers to reporting adverse events and near misses…
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psnet.ahrq.gov/node/33805/psn-pdf
April 01, 2016 - In Conversation With… Thomas J. Nasca, MD, MACP
April 1, 2016
In Conversation With… Thomas J. Nasca, MD, MACP. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp
Editor's note: Dr. Nasca is Chief Executive Officer of the Accreditation Council for Graduate Medical
Educat…
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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)
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psnet.ahrq.gov/clinical-areas
February 26, 2025 - Study
Nurse leader perspectives and experiences on caregiver support following
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psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
August 02, 2015 - SPOTLIGHT CASE
Delay in Initiating Antibiotics Results in Fatal Error
Citation Text:
Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - Nurse Leader . 2020;18(1):44-47. [ Available at ] Ehrmann DE, Gallant SN, Nagaraj S, et al.
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psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-pandemic
October 30, 2024 - A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic
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April 27, 2022
Innovation
Conta…
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psnet.ahrq.gov/innovation/battle-buddies-rapid-deployment-psychological-resilience-intervention-health-care
September 09, 2020 - EMERGING INNOVATIONS
Battle Buddies: rapid deployment of a psychological resilience intervention for health care workers during the COVID-19 pandemic
Citation Text:
Albott CS, Wozniak JR, McGlinch BP, et al. Battle Buddies: rapid deployment of a psychological resilience intervention for health car…
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psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
September 01, 2006 - Errors and Near Misses: What Health Care Could Learn From Aviation
Carl Macrae, PhD | December 1, 2016
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation…
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psnet.ahrq.gov/node/60363/psn-pdf
March 01, 2021 - Transition Coaches® Reduce Readmissions for Medicare
Patients With Complex Postdischarge Needs
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-
postdischarge-needs
Summary
Under a program kn…
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psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
April 24, 2024 - Katie Boston-Leary: The key thing for any leader is to see everyone who reports to deliver care as a
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psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
April 24, 2024 - Katie Boston-Leary: The key thing for any leader is to see everyone who reports to deliver care as a
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psnet.ahrq.gov/issue/what-attributes-patients-affect-their-involvement-safety-key-opinion-leaders-perspective
April 12, 2011 - Study
What attributes of patients affect their involvement in safety? A key opinion leaders' perspective.
Citation Text:
Buetow S, Davis R, Callaghan K, et al. What attributes of patients affect their involvement in safety? A key opinion leaders' perspective. BMJ Open. 2013;3(8):e003104.…
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psnet.ahrq.gov/issue/guidance-health-care-leaders-during-recovery-stage-covid-19-pandemic-consensus-statement
December 21, 2017 - Commentary
Guidance for health care leaders during the recovery stage of the COVID-19 pandemic: a consensus statement.
Citation Text:
Geerts JM, Kinnair D, Taheri P, et al. Guidance for health care leaders during the recovery stage of the COVID-19 pandemic: a consensus statement. JAMA Ne…
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psnet.ahrq.gov/node/33612/psn-pdf
May 01, 2005 - Organizational Change in the Face of Highly Public
Errors—I. The Dana-Farber Cancer Institute Experience
May 1, 2005
Conway JB, Weingart SN. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber
Cancer Institute Experience. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/organizat…
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psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
February 01, 2011 - The University of Texas System Clinical Safety and Effectiveness Course
Eric J. Thomas, MD, MPH; Jan Patterson, MD, MS; Sherry Martin, MEd; Doris Quinn, PhD; Gary Reed, MD; Ken Shine, MD | February 1, 2011
View more articles from the same authors.
Citation Text:
T…
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psnet.ahrq.gov/node/49588/psn-pdf
August 01, 2009 - Each unit's hours can then be tallied, and an internal pool leader can hire nurses to cover this time
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psnet.ahrq.gov/node/33787/psn-pdf
January 01, 2018 - So what have you learned as the leader that you didn't know as second in
command?
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psnet.ahrq.gov/issue/patient-and-family-advisory-council-pfac-toolkit-exploring-diagnostic-quality
November 08, 2017 - Toolkit
Patient and Family Advisory Council (PFAC) Toolkit for Exploring Diagnostic Quality.
Citation Text:
Patient and Family Advisory Council (PFAC) Toolkit for Exploring Diagnostic Quality. Alpharetta, GA: Society to Improve Diagnosis in Medicine; February 2024.
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psnet.ahrq.gov/node/46029/psn-pdf
October 11, 2017 - Closing the gap and raising the bar: assessing board
competency in quality and safety.
October 11, 2017
McGaffigan PA, Ullem BD, Gandhi TK. Closing the Gap and Raising the Bar: Assessing Board
Competency in Quality and Safety. Jt Comm J Qual Patient Saf. 2017;43(6):267-274.
doi:10.1016/j.jcjq.2017.03.003.
https:/…