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3201. Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
      January 01, 2023 - Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx Spotlight A Missed Bowel Perforation – the Importance of Diagnostic Reasoning Source and Credits • This presentation is based on the September 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/web…

3202. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/848754
      January 01, 2025 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Implementation of Patient Safety Projects Curated Library Foundations Leading change: why transformation efforts fail. Kotter JP. Harvard Bus Rev  1995;73(2);59-67. Kotter, a professor at Harvard Business School, outlines the eight stages …

3203. Meeting Minutes, July 2021 | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/events/nac/2021-07-nac/nacmtg071421-minutes.html
      December 01, 2021 - Meeting Minutes, July 2021 Virtual Meeting Minutes from the July 14, 2021, virtual meeting of the Agency for Healthcare Research and Quality's National Advisory Council. Contents Summary Call to Order and Approval of March 18, 2021, Meeting Summary Recent AHRQ Accomplishments AHRQ Budget Opportuniti…

3204. Meeting Minutes, April 2016 | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/events/nac/2016-04-nac/nacmtg0416-minutes.html
      August 01, 2016 - Meeting Minutes, April 2016 National Advisory Council Minutes from the April 20, 2016, meeting of the Agency for Healthcare Research and Quality's National Advisory Council. Contents Summary Call to Order and Approval of November 3, 2015, Summary Report Acting Director's Update AHRQ’S Work in Primar…

3205. Learning Health Systems for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
      February 26, 2025 - spearheaded by the Learning Health Community that Charles Friedman from the University of Michigan leads

3206. In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
      February 26, 2025 - spearheaded by the Learning Health Community that Charles Friedman from the University of Michigan leads

3207. Methods (continued, 2) | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamily3a.html
      July 01, 2018 - the enhanced reputation of the organization, increased satisfaction among employees (which in turn leads

3208. Final Progress Report: Virtual Healthcare Environments Versus Traditional Interactive Team Training (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/taekman-report.pdf
      January 01, 2024 - If it is true that VE training leads to better retention of teamwork and communication skills over time

3209. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42724/psn-pdf
      December 06, 2013 - Adverse drug events after hospital discharge in older adults: types, severity, and involvement of Beers criteria medications. December 6, 2013 Kanaan AO, Donovan JL, Duchin NP, et al. Adverse drug events after hospital discharge in older adults: types, severity, and involvement of Beers Criteria Medications. J Am …

3210. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867634/psn-pdf
      February 26, 2025 - Using simulation to augment root cause analysis for patient safety incidents at a tertiary care women's and children's hospital: a qualitative feasibility study. February 26, 2025 Burchell D, MacPhee S, Sinclair D, et al. Using simulation to augment root cause analysis for patient safety incidents at a tertiary ca…

3211. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867600/psn-pdf
      January 22, 2025 - Application of a digital quality measure for cancer diagnosis in Epic Cosmos. January 22, 2025 Zimolzak AJ, Khan SP, Singh H, et al. Application of a digital quality measure for cancer diagnosis in Epic Cosmos. J Am Med Inform Assoc. 2025;32(1):227-229. doi:10.1093/jamia/ocae253. https://psnet.ahrq.gov/issue/appli…

3212. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837035/psn-pdf
      May 04, 2022 - Is it time for the mental health field to consider unplanned discharge a key metric of patient safety? May 4, 2022 Riblet NB, Gottlieb DJ, Watts BV, et al. Is it time for the mental health field to consider unplanned discharge a key metric of patient safety? J Nerv Ment Dis. 2022;210(3):227-230. doi:10.1097/nmd.00…

3213. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842423/psn-pdf
      January 11, 2023 - Posttraumatic growth and second victim distress resulting from medical mishaps among physicians and nurses. January 11, 2023 Pado K, Fraus K, Mulhem E, et al. Posttraumatic growth and second victim distress resulting from medical mishaps among physicians and nurses. J Clin Psychol Med Settings. 2023;30(4):716-723.…

3214. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848811/psn-pdf
      May 10, 2023 - Types of diagnostic errors reported by paediatric emergency providers in a global paediatric emergency care research network. May 10, 2023 Mahajan P, Grubenhoff JA, Cranford J, et al. Types of diagnostic errors reported by paediatric emergency providers in a global paediatric emergency care research network. BMJ O…

3215. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/862126/psn-pdf
      February 07, 2024 - Why is safety in intrapartum electronic fetal monitoring so hard? A qualitative study combining human factors/ergonomics and social science analysis. February 7, 2024 Lamé G, Liberati EG, Canham A, et al. Why is safety in intrapartum electronic fetal monitoring so hard? A qualitative study combining human factors/…

3216. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38865/psn-pdf
      April 04, 2011 - Afraid in the hospital: parental concern for errors during a child's hospitalization. April 4, 2011 Tarini BA, Lozano P, Christakis DA. Afraid in the hospital: parental concern for errors during a child's hospitalization. J Hosp Med. 2009;41(9):521-527. doi:10.1002/jhm.508. https://psnet.ahrq.gov/issue/afraid-hosp…

3217. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836926/psn-pdf
      April 13, 2022 - Overall performance of a drug-drug interaction clinical decision support system: quantitative evaluation and end- user survey. April 13, 2022 Van De Sijpe G, Quintens C, Walgraeve K, et al. Overall performance of a drug–drug interaction clinical decision support system: quantitative evaluation and end-user survey.…

3218. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46472/psn-pdf
      August 20, 2018 - Wide variation and overprescription of opioids after elective surgery. August 20, 2018 Thiels CA, Anderson SS, Ubl DS, et al. Wide Variation and Overprescription of Opioids After Elective Surgery. Ann Surg. 2017;266(4):564-573. doi:10.1097/SLA.0000000000002365. https://psnet.ahrq.gov/issue/wide-variation-and-overp…

3219. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45317/psn-pdf
      August 17, 2016 - Partnered pharmacist charting on admission in the general medical and emergency short-stay unit—a cluster-randomised controlled trial in patients with complex medication regimens. August 17, 2016 Tong EY, Roman C, Mitra B, et al. Partnered pharmacist charting on admission in the General Medical and Emergency Shor…

3220. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45244/psn-pdf
      August 01, 2016 - Sleep science, schedules, and safety in hospitals: challenges and solutions for pediatric providers. August 1, 2016 Rosenbluth G, Landrigan CP. Sleep science, schedules, and safety in hospitals: challenges and solutions for pediatric providers. Pediatr Clin North Am. 2012;59(6):1317-28. doi:10.1016/j.pcl.2012.09.00…