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  1. Unintended transplantation of three organs from an HIV-positive donor: report of the analysis of an adverse event in a regional health care service in Italy. | PSNet

    psnet.ahrq.gov/issue/unintended-transplantation-three-organs-hiv-positive-donor-report-analysis-adverse-event
    January 24, 2018 - Commentary Unintended transplantation of three organs from an HIV-positive donor: report of the analysis of an adverse event in a regional health care service in Italy. Citation Text: Bellandi T, Albolino S, Tartaglia R, et al. Unintended transplantation of three organs from an HIV-posi…

  2. Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. | PSNet

    psnet.ahrq.gov/issue/feedback-loop-failure-modes-medical-diagnosis-how-biases-can-emerge-and-be-reinforced
    November 01, 2023 - Study Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. Citation Text: Aikens RC, Chen JH, Baiocchi M, et al. Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. Med Decis Making. 2024;44(5):481-496. doi:10.1…

  3. Program access, depressive symptoms, and medical errors among resident physicians with disability. | PSNet

    psnet.ahrq.gov/issue/program-access-depressive-symptoms-and-medical-errors-among-resident-physicians-disability
    May 19, 2021 - Study Program access, depressive symptoms, and medical errors among resident physicians with disability. Citation Text: Meeks LM, Pereira-Lima K, Frank E, et al. Program access, depressive symptoms, and medical errors among resident physicians with disability. JAMA Netw Open. 2021;4(12):…

  4. Prevalence and Burden of Healthcare-Associated Infections (HAIs), 2016–2021. HCUP Statistical Brief #313. | PSNet

    psnet.ahrq.gov/issue/prevalence-and-burden-healthcare-associated-infections-hais-2016-2021-hcup-statistical-brief
    December 18, 2024 - Book/Report Prevalence and Burden of Healthcare-Associated Infections (HAIs), 2016–2021. HCUP Statistical Brief #313. Citation Text: Miller MA, Umscheid CA, Dowell J, et al. Prevalence And Burden Of Healthcare-Associated Infections (Hais), 2016–2021. Hcup Statistical Brief #313. Rockvill…

  5. Improving resident education and patient safety: a method to balance initial caseloads at academic year-end transfer. | PSNet

    psnet.ahrq.gov/issue/improving-resident-education-and-patient-safety-method-balance-initial-caseloads-academic
    January 27, 2016 - Study Improving resident education and patient safety: a method to balance initial caseloads at academic year-end transfer. Citation Text: Young JQ, Niehaus B, Lieu SC, et al. Improving resident education and patient safety: a method to balance initial caseloads at academic year-end tran…

  6. Errors in the MRI evaluation of musculoskeletal tumors and tumorlike lesions. | PSNet

    psnet.ahrq.gov/issue/errors-mri-evaluation-musculoskeletal-tumors-and-tumorlike-lesions
    September 04, 2019 - Study Errors in the MRI evaluation of musculoskeletal tumors and tumorlike lesions. Citation Text: Heck RK, O'Malley AM, Kellum EL, et al. Errors in the MRI evaluation of musculoskeletal tumors and tumorlike lesions. Clin Orthop Relat Res. 2007;459:28-33. Copy Citation Format: …

  7. Disparities in diagnostic timeliness and outcomes of pediatric appendicitis. | PSNet

    psnet.ahrq.gov/issue/disparities-diagnostic-timeliness-and-outcomes-pediatric-appendicitis
    September 13, 2023 - Study Disparities in diagnostic timeliness and outcomes of pediatric appendicitis. Citation Text: Michelson KA, Bachur RG, Rangel SJ, et al. Disparities in diagnostic timeliness and outcomes of pediatric appendicitis. JAMA Netw Open. 2024;7(1):e2353667. doi:10.1001/jamanetworkopen.2023.5…

  8. Unconscious bias among health professionals: a scoping review. | PSNet

    psnet.ahrq.gov/issue/unconscious-bias-among-health-professionals-scoping-review
    December 10, 2008 - Review Unconscious bias among health professionals: a scoping review. Citation Text: Meidert U, Dönnges G, Bucher T, et al. Unconscious bias among health professionals: a scoping review. Int J Environ Res Public Health. 2023;20(16):6569. doi:10.3390/ijerph20166569. Copy Citation Fo…

  9. Information loss in emergency medical services handover of trauma patients. | PSNet

    psnet.ahrq.gov/issue/information-loss-emergency-medical-services-handover-trauma-patients
    August 04, 2021 - Study Information loss in emergency medical services handover of trauma patients. Citation Text: Carter AJE, Davis KA, Evans L, et al. Information loss in emergency medical services handover of trauma patients. Prehosp Emerg Care. 2009;13(3):280-5. doi:10.1080/10903120802706260. Copy …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33662/psn-pdf
    January 01, 2008 - from one particular hospital, and your instinct might be that it would be great to have 50 hospitals learn

  11. In Conversation With… Erik Hollnagel, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
    February 26, 2025 - in health care is looking at the work-as-done and then seeing how people do workarounds and how you learn

  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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