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  1. VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events. | PSNet

    psnet.ahrq.gov/issue/va-health-care-improvements-needed-processes-used-address-providers-actions-contribute
    October 12, 2022 - Book/Report VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events. Citation Text: VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events. Draper D. Washington,…

  2. The impact of drug shortages on patients with cardiovascular disease: causes, consequences, and a call to action. | PSNet

    psnet.ahrq.gov/issue/impact-drug-shortages-patients-cardiovascular-disease-causes-consequences-and-call-action
    October 10, 2012 - Review The impact of drug shortages on patients with cardiovascular disease: causes, consequences, and a call to action. Citation Text: Reed BN, Fox ER, Konig M, et al. The impact of drug shortages on patients with cardiovascular disease: causes, consequences, and a call to action. Am He…

  3. Context-sensitive decision support (infobuttons) in electronic health records: a systematic review. | PSNet

    psnet.ahrq.gov/issue/context-sensitive-decision-support-infobuttons-electronic-health-records-systematic-review
    August 23, 2023 - Review Context-sensitive decision support (infobuttons) in electronic health records: a systematic review. Citation Text: Cook DA, Teixeira MT, Heale BS, et al. Context-sensitive decision support (infobuttons) in electronic health records: a systematic review. J Am Med Inform Assoc. 2017…

  4. Sleep and circadian misalignment for the hospitalist: a review. | PSNet

    psnet.ahrq.gov/issue/sleep-and-circadian-misalignment-hospitalist-review
    July 15, 2020 - Review Sleep and circadian misalignment for the hospitalist: a review. Citation Text: Schaefer EW, Williams M, Zee PC. Sleep and circadian misalignment for the hospitalist: a review. J Hosp Med. 2012;7(6):489-96. doi:10.1002/jhm.1903. Copy Citation Format: DOI Google Schola…

  5. Targeting zero harm: a stretch goal that risks breaking the spring. | PSNet

    psnet.ahrq.gov/issue/targeting-zero-harm-stretch-goal-risks-breaking-spring
    December 01, 2021 - Commentary Targeting zero harm: a stretch goal that risks breaking the spring. Citation Text: Meddings J, Saint S, Lilford RJ, et al. Targeting zero harm: a stretch goal that risks breaking the spring. NEJM Catal Innov Care Deliv. 2020;1(4). doi:10.1056/cat.20.0354. Copy Citation F…

  6. Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report. | PSNet

    psnet.ahrq.gov/issue/goals-and-priorities-health-care-organizations-improve-safety-using-health-it-revised-report
    May 13, 2015 - Book/Report Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report. Citation Text: Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report. Graber ML, Bailey R, Johnston D. RTI International; Washi…

  7. Relationships among psychological safety, the principles of high reliability, and safety reporting intentions in pediatric nursing. | PSNet

    psnet.ahrq.gov/issue/relationships-among-psychological-safety-principles-high-reliability-and-safety-reporting
    September 16, 2015 - Study Relationships among psychological safety, the principles of high reliability, and safety reporting intentions in pediatric nursing. Citation Text: Pfeifer L, Vessey J, Cazzell M, et al. Relationships among psychological safety, the principles of high reliability, and safety reporti…

  8. Flow accuracy of IV smart pumps outside of patient rooms during COVID-19. | PSNet

    psnet.ahrq.gov/issue/flow-accuracy-iv-smart-pumps-outside-patient-rooms-during-covid-19
    October 12, 2022 - Commentary Flow accuracy of IV smart pumps outside of patient rooms during COVID-19. Citation Text: Blake JWC, Giuliano KK. Flow accuracy of IV smart pumps outside of patient rooms during COVID-19. AACN Adv Crit Care. 2020;31(4):357-363. doi:10.4037/aacnacc2020241. Copy Citation Fo…

  9. Don't go to the hospital alone: ensuring safe, highly reliable patient visitation. | PSNet

    psnet.ahrq.gov/issue/dont-go-hospital-alone-ensuring-safe-highly-reliable-patient-visitation
    May 12, 2021 - Commentary Don't go to the hospital alone: ensuring safe, highly reliable patient visitation. Citation Text: Gandhi TK. Don't go to the hospital alone: ensuring safe, highly reliable patient visitation. Jt Comm J Qual Patient Saf. 2022;48(1):61-64. doi:10.1016/j.jcjq.2021.10.006. Copy …

  10. Adverse Events in Hospitals: State Reporting Systems. | PSNet

    psnet.ahrq.gov/issue/adverse-events-hospitals-state-reporting-systems
    January 14, 2009 - Book/Report Adverse Events in Hospitals: State Reporting Systems. Citation Text: Adverse Events in Hospitals: State Reporting Systems. Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00471. …

  11. Measuring preventable harm: helping science keep pace with policy.   | PSNet

    psnet.ahrq.gov/issue/measuring-preventable-harm-helping-science-keep-pace-policy
    December 29, 2014 - Commentary Measuring preventable harm: helping science keep pace with policy.   Citation Text: Pronovost P, Colantuoni E. Measuring preventable harm: helping science keep pace with policy. JAMA. 2009;301(12):1273-5. doi:10.1001/jama.2009.388. Copy Citation Format: DOI Goo…

  12. Learning from the best. | PSNet

    psnet.ahrq.gov/issue/learning-best
    February 22, 2023 - Newspaper/Magazine Article Learning from the best. Citation Text: Grantham D. Learning from the best. Behavioral healthcare. 2010;30(4):22-4. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Cit…

  13. Patient Safety Learning. | PSNet

    psnet.ahrq.gov/issue/patient-safety-learning
    January 12, 2022 - Multi-use Website Patient Safety Learning. Citation Text: Patient Safety Learning. Patient Safety Learning. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …

  14. Learning From Mistakes. | PSNet

    psnet.ahrq.gov/issue/learning-mistakes
    March 28, 2018 - July 19, 2023 Unlocking Solutions in Imaging: Working Together to Learn from Failings

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43253/psn-pdf
    May 01, 2015 - interim-report-review-vhas-patient-wait-times-scheduling-practices-and-alleged-patient-deaths https://psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation

  16. In Conversation With… Susan E. Skochelak, MD, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd
    February 01, 2019 - RW : How has the drive to rethink the content of the curriculum (what learners needed to learn) synced … the health care system around bringing these concepts front and center into the way in which students learn … We want to learn from you, we want to evaluate together, and we want to rapidly disseminate best practices … We're worried they might feel like why did I learn all of that or why did I get invested in all of that … a state we refer to as being a systems citizen.( 6-8 ) For such a paradigm shift, providers need to learn

  17. Building a learning organization. | PSNet

    psnet.ahrq.gov/issue/building-learning-organization
    June 16, 2011 - Study Classic Building a learning organization. Citation Text: Garvin DA. Building a learning organization. Harv Bus Rev. 1993;71(4):78-91. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…

  18. Learning Health Systems | PSNet

    psnet.ahrq.gov/issue/learning-health-systems
    December 24, 2008 - Multi-use Website Learning Health Systems Citation Text: Learning Health Systems Agency for Health Research and Quality. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …

  19. Shifting the learning curve. | PSNet

    psnet.ahrq.gov/issue/shifting-learning-curve
    March 09, 2009 - Commentary Shifting the learning curve. Citation Text: Reynolds T, Kong M-L. Shifting the learning curve. BMJ. 2010;341:c6260. doi:10.1136/bmj.c6260. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  20. Learning from Investigations. | PSNet

    psnet.ahrq.gov/issue/learning-investigations
    July 28, 2013 - Book/Report Learning from Investigations. Citation Text: Learning from Investigations. Commission for Healthcare Audit and Inspection. London, England; Healthcare Commission: 2008. ISBN 9781845621636. Copy Citation Save Save to your library Print Downlo…
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