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8361. The value of autopsies in the era of high-tech medicine: discrepant findings persist. | PSNet
      psnet.ahrq.gov/issue/value-autopsies-era-high-tech-medicine-discrepant-findings-persist
      October 18, 2023 - Study The value of autopsies in the era of high-tech medicine: discrepant findings persist. Citation Text: Kuijpers CCHJ, Fronczek J, van de Goot FRW, et al. The value of autopsies in the era of high-tech medicine: discrepant findings persist. J Clin Pathol. 2014;67(6):512-9. doi:10.1136…

8362. Improving patient safety in the ICU by prospective identification of missing safety barriers using the Bow-Tie prospective risk analysis model. | PSNet
      psnet.ahrq.gov/issue/improving-patient-safety-icu-prospective-identification-missing-safety-barriers-using-bow-tie
      February 14, 2024 - Study Improving patient safety in the ICU by prospective identification of missing safety barriers using the Bow-Tie prospective risk analysis model. Citation Text: Kerckhoffs MC, van der Sluijs AF, Binnekade JM, et al. Improving Patient Safety in the ICU by Prospective Identification o…

8363. Interventions to improve team effectiveness within health care: a systematic review of the past decade. | PSNet
      psnet.ahrq.gov/issue/interventions-improve-team-effectiveness-within-health-care-systematic-review-past-decade
      March 05, 2010 - Review Classic Interventions to improve team effectiveness within health care: a systematic review of the past decade. Citation Text: Buljac-Samardzic M, Doekhie KD, van Wijngaarden JDH. Interventions to improve team effectiveness within health care: a systemati…

8364. A report of information technology and health deficiencies in U.S. nursing homes. | PSNet
      psnet.ahrq.gov/issue/report-information-technology-and-health-deficiencies-us-nursing-homes
      October 28, 2020 - Study A report of information technology and health deficiencies in U.S. nursing homes. Citation Text: Alexander GL, Madsen RW. A report of information technology and health deficiencies in U.S. nursing homes. J Patient Saf. 2021;17(6):e483-e489. doi:10.1097/pts.0000000000000390. Copy …

8365. Non-conveyance of older adult patients and association with subsequent clinical and adverse events after initial assessment by ambulance clinicians: a cohort analysis. | PSNet
      psnet.ahrq.gov/issue/non-conveyance-older-adult-patients-and-association-subsequent-clinical-and-adverse-events
      October 27, 2021 - Study Non-conveyance of older adult patients and association with subsequent clinical and adverse events after initial assessment by ambulance clinicians: a cohort analysis. Citation Text: Lederman J, Lindström V, Elmqvist C, et al. Non-conveyance of older adult patients and association …

8366. Clinical predictors for unsafe direct discharge home patients from intensive care units. | PSNet
      psnet.ahrq.gov/issue/clinical-predictors-unsafe-direct-discharge-home-patients-intensive-care-units
      January 12, 2011 - Study Clinical predictors for unsafe direct discharge home patients from intensive care units. Citation Text: Lau VI, Priestap FA, Lam JNH, et al. Clinical predictors for unsafe direct discharge home patients from intensive care units. J Intensive Care Med. 2020;35(10):1067-1073. doi:10.…

8367. Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery. | PSNet
      psnet.ahrq.gov/issue/reducing-burden-surgical-harm-systematic-review-interventions-used-reduce-adverse-events
      June 21, 2016 - Review Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery. Citation Text: Howell A-M, Panesar S, Burns EM, et al. Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse eve…

8368. An ethnographic study of health information technology use in three intensive care units. | PSNet
      psnet.ahrq.gov/issue/ethnographic-study-health-information-technology-use-three-intensive-care-units
      January 14, 2014 - Study An ethnographic study of health information technology use in three intensive care units. Citation Text: Leslie M, Paradis E, Gropper MA, et al. An Ethnographic Study of Health Information Technology Use in Three Intensive Care Units. Health Serv Res. 2017;52(4):1330-1348. doi:10.1…

8369. P | Agency for Healthcare Research and Quality
      www.ahrq.gov/topics/p.html
      June 12, 2025 - Topics Browse A - Z P Palliative Care Patient and Family Engagement Patient Experience Patient Safety Patient Safety Learning Labs Patient Safety Organizations Patient Self-Management Patient-Centered Healthcare Patient-Centered Outcomes Research Patients and Consumers Policy …

8370. Additional Tools and Resources | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod2tools.html
      March 01, 2018 - Module 2: Communicating Change in a Resident's Condition Additional Tools and Resources Previous Page Next Page Table of Contents Module 2: Communicating Change in a Resident's Condition Learning and Performance Objectives Session 1 Session 2 Conclusion Additional Tools and Resources App…

8371. Patient-Centered Outcomes Research | Agency for Healthcare Research and Quality
      www.ahrq.gov/topics/patient-centered-outcomes-research.html
      Topic: Patient-Centered Outcomes Research Listing of content related to the topic Patient-Centered Outcomes Research About the Patient-Centered Outcomes Research Trust Fund AHRQ and the Patient-Centered Outcomes Research Institute Collaborate to Train a New Generation…

8372. COVID-19: How To Put On and Remove Personal Protective Equipment (PPE) | Agency for Healthcare Research and Quality
      www.ahrq.gov/nursing-home/resources/how-to-put-on-ppe.html
      June 01, 2022 - COVID-19: How To Put On and Remove Personal Protective Equipment (PPE) Resource: COVID-19: How To Put On and Remove Personal Protective Equipment (PPE) ​This is a guide for health care workers involved in patient care activities in a health care setting. It aims to show the type of personal protective equip…

8373. Infection Preventionist Specialized Training | Agency for Healthcare Research and Quality
      www.ahrq.gov/nursing-home/resources/infection-preventionist-training.html
      April 01, 2022 - Infection Preventionist Specialized Training Resource: Infection Preventionist Specialized Training The American Health Care Association ​Infection Preventionist Specialized Training is a specialized course of study for healthcare professionals who desire to serve as infection preventionists. Through this p…

8374. PSO General Information | PSO
      pso.ahrq.gov/taxonomy/term/2
      SHARE: What are "patient safety activities"? Read more about What are "patient safety activities"? There are eight patient safety activities that are carried out by, or on behalf of a PSO, or a healthcare provider: What i…

8375. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41314/psn-pdf
      September 27, 2016 - The Medical Apology: Making It Right When Things Go Wrong. September 27, 2016 Schulte MF, ed. Front Health Serv Manage. 2012;28(3):1-46. https://psnet.ahrq.gov/issue/medical-apology-making-it-right-when-things-go-wrong Articles in this special issue highlight lessons learned from disclosure and apology in health c…

8376. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36857/psn-pdf
      January 22, 2017 - Eliminating perioperative adverse events at Ascension Health. January 22, 2017 Ewing H, Bruder G, Baroco P, et al. Eliminating perioperative adverse events at Ascension Health. Jt Comm J Qual Patient Saf. 2007;33(5):256-66. https://psnet.ahrq.gov/issue/eliminating-perioperative-adverse-events-ascension-health The…

8377. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40650/psn-pdf
      July 27, 2011 - Level IV evidence—adverse anecdote and clinical practice. July 27, 2011 Stuebe AM. Level IV evidence--adverse anecdote and clinical practice. N Engl J Med. 2011;365(1):8-9. doi:10.1056/NEJMp1102632. https://psnet.ahrq.gov/issue/level-iv-evidence-adverse-anecdote-and-clinical-practice This perspective describes ho…

8378. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41146/psn-pdf
      February 15, 2012 - Adverse events: root causes and latent factors. February 15, 2012 Karl R, Karl MC. Adverse events: root causes and latent factors. Surg Clin North Am. 2012;92(1):89-100. doi:10.1016/j.suc.2011.12.003. https://psnet.ahrq.gov/issue/adverse-events-root-causes-and-latent-factors This commentary uses scenarios to illus…

8379. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35247/psn-pdf
      December 17, 2008 - Review of the Australian Incident Monitoring System. December 17, 2008 Spigelman AD, Swan J. Review of the Australian incident monitoring system. ANZ J Surg. 2005;75(8):657- 61. https://psnet.ahrq.gov/issue/review-australian-incident-monitoring-system The authors surveyed users of the Australian Incident Monitorin…

8380. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41599/psn-pdf
      August 15, 2012 - The concept of error and malpractice in radiology. August 15, 2012 Pinto A, Brunese L, Pinto F, et al. The concept of error and malpractice in radiology. Semin Ultrasound CT MR. 2012;33(4):275-9. doi:10.1053/j.sult.2012.01.009. https://psnet.ahrq.gov/issue/concept-error-and-malpractice-radiology This commentary di…