-
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care-2/facilitator-guide.html
July 01, 2023 - Facilitator Guide
AHRQ Safety Program for Perinatal Care, Phase 2
The Facilitator Guide provides guidance with scheduling and conducting facilitation sessions, which are planned, in-person, semistructured, interdisciplinary conversations, and practice opportunities with tier 1 audience members. The Planning F…
-
psnet.ahrq.gov/node/73138/psn-pdf
April 14, 2021 - An act of performance: exploring residents' decision-
making processes to seek help.
April 14, 2021
Jansen I, Stalmeijer RE, Silkens MEWM, et al. An act of performance: exploring residents’ decision?
making processes to seek help. Med Educ. 2021;55(6):758-767. doi:10.1111/medu.14465.
https://psnet.ahrq.gov/issue/a…
-
psnet.ahrq.gov/node/837058/psn-pdf
May 11, 2022 - Establishing psychological safety in clinical supervision:
multi-professional perspectives.
May 11, 2022
Lee EH, Pitts S, Pignataro S, et al. Establishing psychological safety in clinical supervision: multi?
professional perspectives. Clin Teach. 2022;19(2):71-78. doi:10.1111/tct.13451.
https://psnet.ahrq.gov/issu…
-
psnet.ahrq.gov/node/36698/psn-pdf
February 24, 2011 - The impact of duty hours on resident self reports of
errors.
February 24, 2011
Vidyarthi A, Auerbach AD, Wachter R, et al. The impact of duty hours on resident self reports of errors. J
Gen Intern Med. 2007;22(2):205-9.
https://psnet.ahrq.gov/issue/impact-duty-hours-resident-self-reports-errors
Residency programs…
-
psnet.ahrq.gov/node/837853/psn-pdf
August 17, 2022 - RaDonda Vaught, medication safety, and the profession
of pharmacy: steps to improve safety and ensure justice.
August 17, 2022
Lambert BL, Schiff GD. RaDonda Vaught, medication safety, and the profession of pharmacy: steps to
improve safety and ensure justice. J Am Coll Clin Pharm. 2022;5(9):981-987. doi:10.1002/ja…
-
psnet.ahrq.gov/node/60791/psn-pdf
August 12, 2020 - Adaptive design: adaptation and adoption of patient
safety practices in daily routines, a multi-site study.
August 12, 2020
Dekker - van Doorn C, Wauben LSGL, van Wijngaarden JDH, et al. Adaptive design: adaptation and
adoption of patient safety practices in daily routines, a multi-site study. BMC Health Serv Res.
…
-
psnet.ahrq.gov/node/856637/psn-pdf
November 29, 2023 - Deficiencies in Quality Management Processes and
Delays in the Communication of Test Results and Follow-
Up Care at the Phoenix VA Health Care System in Arizona.
November 29, 2023
Washington DC; VA Office of the Inspector General; October 31, 2023; Report no. 22-03599-07.
https://psnet.ahrq.gov/issue/deficiencies-…
-
psnet.ahrq.gov/node/34848/psn-pdf
February 17, 2011 - Improving patient safety—five years after the IOM report.
February 17, 2011
Altman DE, Clancy CM, Blendon RJ. Improving Patient Safety — Five Years after the IOM Report. New
Engl J Med. 2004;351(20):2041-2043. doi:10.1056/nejmp048243.
https://psnet.ahrq.gov/issue/improving-patient-safety-five-years-after-iom-report…
-
psnet.ahrq.gov/node/45640/psn-pdf
September 01, 2018 - Case outcomes in a communication-and-resolution
program in New York hospitals.
September 1, 2018
Mello MM, Greenberg Y, Senecal SK, et al. Case Outcomes in a Communication-and-Resolution Program
in New York Hospitals. Health Serv Res. 2016;51 Suppl 3:2583-2599. doi:10.1111/1475-6773.12594.
https://psnet.ahrq.gov/i…
-
psnet.ahrq.gov/node/860732/psn-pdf
April 16, 2024 - Retained Swabs Following Invasive Procedures: Themes
Identified from a Review of NHS Serious Incident Reports.
April 16, 2024
Dorset, UK: Health Services Safety Investigations Body; April 2024.
https://psnet.ahrq.gov/issue/retained-swabs-following-invasive-procedures-themes-identified-review-nhs-
serious-incident
…
-
psnet.ahrq.gov/node/867010/psn-pdf
October 23, 2024 - Patient safety culture in hospital settings across
continents: a systematic review.
October 23, 2024
Alabdullah H, Karwowski W. Patient safety culture in hospital settings across continents: a systematic
review. Appl Sci. 2024;14(18):8496. doi:10.3390/app14188496.
https://psnet.ahrq.gov/issue/patient-safety-cultur…
-
psnet.ahrq.gov/node/47495/psn-pdf
October 31, 2018 - Developing and evaluating clinical leadership
interventions for frontline healthcare providers: a review
of the literature.
October 31, 2018
Mianda S, Voce A. Developing and evaluating clinical leadership interventions for frontline healthcare
providers: a review of the literature. BMC Health Serv Res. 2018;18(1):…
-
psnet.ahrq.gov/node/45292/psn-pdf
September 07, 2016 - Electronic approaches to making sense of the text in the
adverse event reporting system.
September 7, 2016
Benin AL, Fodeh SJ, Lee K, et al. Electronic approaches to making sense of the text in the adverse event
reporting system. J Healthc Risk Manag. 2016;36(2):10-20. doi:10.1002/jhrm.21237.
https://psnet.ahrq.go…
-
psnet.ahrq.gov/node/837059/psn-pdf
May 11, 2022 - Anti-black racism as a chronic condition.
May 11, 2022
Sederstrom N, Lasege T. Anti-black racism as a chronic condition. Hastings Cent Rep. 2022;52(S1):s24-
s29. doi:10.1002/hast.1364.
https://psnet.ahrq.gov/issue/anti-black-racism-chronic-condition
Racial bias and systemic racism in healthcare are increasingly se…
-
psnet.ahrq.gov/node/47759/psn-pdf
February 06, 2019 - California doctors alarmed as state links their opioid
prescriptions to deaths.
February 6, 2019
Dembosky A. All Things Considered and KQED. January 23, 2019.
https://psnet.ahrq.gov/issue/california-doctors-alarmed-state-links-their-opioid-prescriptions-deaths
Policy, practice, and communication strategies have be…
-
psnet.ahrq.gov/node/47298/psn-pdf
September 24, 2018 - Physician engagement in malpractice risk reduction: a
UPHS case study.
September 24, 2018
Diraviam SP, Sullivan P, Sestito JA, et al. Physician Engagement in Malpractice Risk Reduction: A UPHS
Case Study. Jt Comm J Qual Patient Saf. 2018;44(10):605-612. doi:10.1016/j.jcjq.2018.03.009.
https://psnet.ahrq.gov/issue/…
-
psnet.ahrq.gov/node/47015/psn-pdf
May 09, 2018 - How DeKalb Medical fixed drug safety problems after fatal
error.
May 9, 2018
Porter S. HealthLeaders Media. April 26, 2018.
https://psnet.ahrq.gov/issue/how-dekalb-medical-fixed-drug-safety-problems-after-fatal-error
Overreliance on technology can result in harmful medication mistakes. Reporting on a 10-fold medic…
-
psnet.ahrq.gov/node/45218/psn-pdf
June 15, 2016 - Patient Safety and Quality Improvement Act of 2005--HHS
guidance regarding patient safety work product and
providers' external obligations.
June 15, 2016
Agency for Healthcare Research and Quality. Fed Regist. 2016;81(100);32655-32660.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005-hh…
-
psnet.ahrq.gov/node/46445/psn-pdf
December 19, 2017 - An appeal for evidence-based resident duty hours reform.
December 19, 2017
Khoong EC, Linker AS. An Appeal for Evidence-Based Resident Duty Hours Reform. JAMA Intern Med.
2017;177(11):1555-1556. doi:10.1001/jamainternmed.2017.4469.
https://psnet.ahrq.gov/issue/appeal-evidence-based-resident-duty-hours-reform
The i…
-
psnet.ahrq.gov/node/36837/psn-pdf
December 03, 2018 - Hospitals as cultures of entrapment: a re-analysis of the
Bristol Royal Infirmary.
December 3, 2018
Weick KE, Sutcliffe KM. Hospitals as Cultures of Entrapment: A Re-Analysis of the Bristol Royal Infirmary.
Calif Manage Rev. 2012;45(2):73-84. doi:10.2307/41166166.
https://psnet.ahrq.gov/issue/hospitals-cultures-en…