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  1. Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. | PSNet

    psnet.ahrq.gov/issue/experiences-health-professionals-who-conducted-root-cause-analyses-after-undergoing-safety
    June 14, 2011 - Study Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. Citation Text: Braithwaite J, Westbrook MT, Mallock NA, et al. Experiences of health professionals who conducted root cause analyses after undergoing a safety im…

  2. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. | PSNet

    psnet.ahrq.gov/issue/catastrophic-drug-errors-involving-tranexamic-acid-administered-during-spinal-anaesthesia
    September 23, 2020 - Review Emerging Classic Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Citation Text: Patel S, Robertson B, McConachie I. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Anaes…

  3. Effect of patient safety strategies on the incidence of adverse events. | PSNet

    psnet.ahrq.gov/issue/effect-patient-safety-strategies-incidence-adverse-events
    March 09, 2022 - Study Effect of patient safety strategies on the incidence of adverse events. Citation Text: Sierra AF, del Aguila del MR, Espigares JLN, et al. Effect of patient safety strategies on the incidence of adverse events. J Eval Clin Pract. 2014;20(2):184-90. doi:10.1111/jep.12105. Copy C…

  4. Implementing a patient safety and quality program across two merged pediatric institutions. | PSNet

    psnet.ahrq.gov/issue/implementing-patient-safety-and-quality-program-across-two-merged-pediatric-institutions
    June 03, 2013 - Study Implementing a patient safety and quality program across two merged pediatric institutions. Citation Text: Abramson EL, Hyman D, Osorio N, et al. Implementing a patient safety and quality program across two merged pediatric institutions. Jt Comm J Qual Patient Saf. 2009;35(1):43-…

  5. Year-end resident clinic handoffs: narrative review and recommendations for improvement. | PSNet

    psnet.ahrq.gov/issue/year-end-resident-clinic-handoffs-narrative-review-and-recommendations-improvement
    March 28, 2018 - Review Year-end resident clinic handoffs: narrative review and recommendations for improvement. Citation Text: Pincavage A, Donnelly MJ, Young JQ, et al. Year-End Resident Clinic Handoffs: Narrative Review and Recommendations for Improvement. Jt Comm J Qual Patient Saf. 2017;43(2):71-79.…

  6. Standardization and visualization of the surgical time-out. | PSNet

    psnet.ahrq.gov/issue/standardization-and-visualization-surgical-time-out
    November 06, 2024 - Study Standardization and visualization of the surgical time-out. Citation Text: Levy BE, Wilt WS, Lantz S, et al. Standardization and visualization of the surgical time-out. J Patient Saf. 2023;19(7):453-459. doi:10.1097/pts.0000000000001156. Copy Citation Format: DOI Goog…

  7. Medication safety and the administration of intravenous vincristine: international survey of oncology pharmacists. | PSNet

    psnet.ahrq.gov/issue/medication-safety-and-administration-intravenous-vincristine-international-survey-oncology
    March 26, 2015 - Study Medication safety and the administration of intravenous vincristine: international survey of oncology pharmacists. Citation Text: Gilbar P, Chambers C, Larizza M. Medication safety and the administration of intravenous vincristine: international survey of oncology pharmacists. J On…

  8. Interruptions during the delivery of high-risk medications. | PSNet

    psnet.ahrq.gov/issue/interruptions-during-delivery-high-risk-medications
    September 26, 2016 - Study Interruptions during the delivery of high-risk medications. Citation Text: Trbovich PL, Prakash V, Stewart J, et al. Interruptions during the delivery of high-risk medications. J Nurs Adm. 2010;40(5):211-8. doi:10.1097/NNA.0b013e3181da4047. Copy Citation Format: DOI G…

  9. Impact of system-level activities and reporting design on the number of incident reports for patient safety. | PSNet

    psnet.ahrq.gov/issue/impact-system-level-activities-and-reporting-design-number-incident-reports-patient-safety
    January 20, 2011 - Study Impact of system-level activities and reporting design on the number of incident reports for patient safety. Citation Text: Fukuda H, Imanaka Y, Hirose M, et al. Impact of system-level activities and reporting design on the number of incident reports for patient safety. Qual Saf …

  10. Barriers and facilitators for taking action after classroom-based crew resource management training at three ICUs. | PSNet

    psnet.ahrq.gov/issue/barriers-and-facilitators-taking-action-after-classroom-based-crew-resource-management
    July 10, 2013 - Study Barriers and facilitators for taking action after classroom-based crew resource management training at three ICUs. Citation Text: Kemper PE, van Dyck C, Wagner C, et al. Barriers and facilitators for taking action after classroom-based crew resource management training at three ICU…

  11. Accuracy of skin cancer diagnosis by physician assistants compared with dermatologists in a large health care system. | PSNet

    psnet.ahrq.gov/issue/accuracy-skin-cancer-diagnosis-physician-assistants-compared-dermatologists-large-health-care
    August 04, 2021 - Study Emerging Classic Accuracy of skin cancer diagnosis by physician assistants compared with dermatologists in a large health care system. Citation Text: Anderson AM, Matsumoto M, Saul MI, et al. Accuracy of Skin Cancer Diagnosis by Physician Assistants Compar…

  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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