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psnet.ahrq.gov/node/72613/psn-pdf
December 22, 2020 - One of the things we learned from a culture survey we did
was that the two areas that we were particularly … The difference between medical and dental school that I learned when I
came into the school is that
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psnet.ahrq.gov/node/34735/psn-pdf
June 16, 2014 - goals to create unified reporting mechanisms, support an
open learning culture, ensure that lessons learned
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psnet.ahrq.gov/node/37478/psn-pdf
February 22, 2011 - adversedrugevent
https://psnet.ahrq.gov/issue/intravenous-medication-safety-and-smart-infusion-systems-lessons-learned-and-future
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psnet.ahrq.gov/node/45490/psn-pdf
September 01, 2018 - collaboration-regulators-support-quality-and-accountability-following-medical-errors
https://psnet.ahrq.gov/issue/communication-and-resolution-programs-challenges-and-lessons-learned-six-early-adopters
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psnet.ahrq.gov/node/34849/psn-pdf
May 14, 2012 - improving-patient-safety-five-years-after-iom-report
https://psnet.ahrq.gov/issue/five-years-after-err-human-what-have-we-learned
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psnet.ahrq.gov/node/45350/psn-pdf
October 21, 2016 - This report discusses the need to ensure that lessons
learned in military trauma care are acted on and
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psnet.ahrq.gov/node/47505/psn-pdf
March 19, 2019 - A past PSNet perspective explored insights learned from experience with the
AHRQ-supported teamwork
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psnet.ahrq.gov/issue/defining-high-quality-and-effective-morbidity-and-mortality-conference-systematic-review
September 30, 2012 - Review
Defining a high-quality and effective morbidity and mortality conference: a systematic review.
Citation Text:
Beaulieu-Jones BR, Wilson S, Howard DS, et al. Defining a high-quality and effective morbidity and mortality conference: a systematic review. JAMA Surg. 2023;158(12):1336-…
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psnet.ahrq.gov/issue/application-global-trigger-tool-systematic-review
December 06, 2023 - Review
The application of the Global Trigger Tool: a systematic review.
Citation Text:
Hibbert PD, Molloy CJ, Hooper TD, et al. The application of the Global Trigger Tool: a systematic review. Int J Qual Health Care. 2016;28(6):640-649. doi:10.1093/intqhc/mzw115.
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psnet.ahrq.gov/issue/scoping-review-adverse-incidents-research-aged-care-homes-learnings-gaps-and-challenges
November 18, 2020 - Review
A scoping review of adverse incidents research in aged care homes: learnings, gaps, and challenges.
Citation Text:
St Clair B, Jorgensen M, Nguyen A, et al. A scoping review of adverse incidents research in aged care homes: learnings, gaps, and challenges. Gerontol Geriatr Med. 20…
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psnet.ahrq.gov/issue/call-action-next-steps-advance-diagnosis-education-health-professions
November 25, 2020 - Commentary
A call to action: next steps to advance diagnosis education in the health professions.
Citation Text:
Graber ML, Holmboe ES, Stanley J, et al. A call to action: next steps to advance diagnosis education in the health professions. Diagnosis (Berl). 2022;9(2):166-175. doi:10.151…
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psnet.ahrq.gov/issue/use-strategies-high-reliability-organisations-patient-hand-resident-physicians-practical
July 02, 2014 - Study
Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications.
Citation Text:
Philibert I. Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications. Qu…
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psnet.ahrq.gov/issue/assessment-impact-just-culture-quality-and-safety-us-hospitals
April 13, 2017 - Study
Emerging Classic
An assessment of the impact of just culture on quality and safety in US hospitals.
Citation Text:
Edwards MT. An Assessment of the Impact of Just Culture on Quality and Safety in US Hospitals. Am J Med Qual. 2018;33(5):502-508. doi:10.1177…
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psnet.ahrq.gov/issue/beyond-find-and-fix-improving-quality-and-safety-through-resilient-healthcare-systems
August 04, 2021 - Study
Beyond 'find and fix': improving quality and safety through resilient healthcare systems.
Citation Text:
Anderson JE, Ross AJ, Back J, et al. Beyond ‘find and fix’: improving quality and safety through resilient healthcare systems. Int J Qual Health Care. 2020;32(3):204-211. doi:10…
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psnet.ahrq.gov/issue/bias-warp-speed-how-ai-may-contribute-disparities-gap-time-covid-19
July 22, 2020 - Commentary
Bias at warp speed: how AI may contribute to the disparities gap in the time of COVID-19.
Citation Text:
Röösli E, Rice B, Hernandez-Boussard T. Bias at Warp Speed: How AI may Contribute to the Disparities Gap in the Time of COVID-19. J Am Med Inform Assoc. 2021;28(1):190-192.…
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psnet.ahrq.gov/issue/world-federation-chiropractic-global-patient-safety-task-force-call-action
December 23, 2020 - Review
The World Federation of Chiropractic Global Patient Safety Task Force: a call to action.
Citation Text:
Coleman BC, Rubinstein SM, Salsbury SA, et al. The World Federation of Chiropractic Global Patient Safety Task Force: a call to action. Chiropr Man Therap. 2024;32(1):15. doi:10…
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psnet.ahrq.gov/issue/register-based-research-adverse-events-revealing-incomplete-records-threatening-patient
October 06, 2021 - Review
Register-based research of adverse events revealing incomplete records threatening patient safety.
Citation Text:
Kinnunen U-M, Kivekäs E, Palojoki S, et al. Register-based research of adverse events revealing incomplete records threatening patient safety. Stud Health Technol Info…
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psnet.ahrq.gov/issue/improving-situation-awareness-reduce-unrecognized-clinical-deterioration-and-serious-safety
December 02, 2014 - Study
Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.
Citation Text:
Brady PW, Muething S, Kotagal U, et al. Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. Pediatrics. 2013;131(…
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psnet.ahrq.gov/issue/patient-centered-insights-using-health-care-complaints-reveal-hot-spots-and-blind-spots
November 29, 2023 - Study
Emerging Classic
Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety.
Citation Text:
Gillespie A, Reader TW. Patient-Centered Insights: Using Health Care Complaints to Reveal Hot Spots and Blind…
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psnet.ahrq.gov/issue/debrief-it-all-tool-inclusion-safety-ii
June 08, 2022 - Study
Debrief it all: a tool for inclusion of Safety-II.
Citation Text:
Bentley SK, McNamara S, Meguerdichian MJ, et al. Debrief it all: a tool for inclusion of Safety-II. Adv Simul (Lond). 2021;6(1):9. doi:10.1186/s41077-021-00163-3.
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