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psnet.ahrq.gov/node/60969/psn-pdf
November 08, 2023 - Network of Patient Safety Databases Chartbook.
November 8, 2023
Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-
0082.
https://psnet.ahrq.gov/issue/network-patient-safety-databases-chartbook
The sharing of data is a core element of a learning health system. AHRQ h…
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psnet.ahrq.gov/node/865974/psn-pdf
May 29, 2024 - Minimizing bias when using artificial intelligence in
critical care medicine.
May 29, 2024
Ranard BL, Park S, Jia Y, et al. Minimizing bias when using artificial intelligence in critical care medicine. J
Crit Care. 2024;82:154796. doi:10.1016/j.jcrc.2024.154796.
https://psnet.ahrq.gov/issue/minimizing-bias-when-us…
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psnet.ahrq.gov/node/47555/psn-pdf
November 14, 2018 - How one hospital improved patient safety in 10 minutes a
day.
November 14, 2018
van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018.
https://psnet.ahrq.gov/issue/how-one-hospital-improved-patient-safety-10-minutes-day
Aviation continues to provide inspiration for patient safety innovation. This commentar…
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psnet.ahrq.gov/node/43178/psn-pdf
July 28, 2014 - Safety measurement and monitoring in healthcare: a
framework to guide clinical teams and healthcare
organisations in maintaining safety.
July 28, 2014
Vincent CA, Burnett S, Carthey J. Safety measurement and monitoring in healthcare: a framework to guide
clinical teams and healthcare organisations in maintaining s…
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psnet.ahrq.gov/node/60034/psn-pdf
March 11, 2020 - Responding to unprofessional behavior by trainees - a
"just culture" framework.
March 11, 2020
Wasserman JA, Redinger M, Gibb T. Responding to Unprofessional Behavior by Trainees — A “Just
Culture” Framework. New England Journal of Medicine. 2020;382(8). doi:10.1056/nejmms1912591.
https://psnet.ahrq.gov/issue/resp…
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psnet.ahrq.gov/node/38509/psn-pdf
April 01, 2009 - Restricted duty hours for surgeons and impact on
residents quality of life, education, and patient care: a
literature review.
April 1, 2009
Pape H-C, Pfeifer R. Restricted duty hours for surgeons and impact on residents quality of life, education,
and patient care: a literature review. Patient Saf Surg. 2009;3(1):…
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psnet.ahrq.gov/node/46028/psn-pdf
July 05, 2017 - The role of morbidity and mortality rounds in medical
education: a scoping review.
July 5, 2017
Benassi P, MacGillivray L, Silver I, et al. The role of morbidity and mortality rounds in medical education: a
scoping review. Med Educ. 2017;51(5):469-479. doi:10.1111/medu.13234.
https://psnet.ahrq.gov/issue/role-morb…
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psnet.ahrq.gov/node/46350/psn-pdf
September 24, 2017 - Time for transparent standards in quality reporting by
health care organizations.
September 24, 2017
Pronovost P, Wu AW, Austin M. Time for Transparent Standards in Quality Reporting by Health Care
Organizations. JAMA. 2017;318(8):701-702. doi:10.1001/jama.2017.10124.
https://psnet.ahrq.gov/issue/time-transparent-…
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digital.ahrq.gov/ahrq-funded-projects/developing-evidence-based-user-centered-design-and-implementation-guidelines/final-report
January 01, 2023 - Developing Evidence-Based, User-Centered Design and Implementation Guidelines to Improve Health Information Technology Usability - Final Report
Citation
Ratwani R. Developing Evidence-Based, User-Centered Design and Implementation Guidelines to Improve Health Information Technology Usability - Final R…
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psnet.ahrq.gov/node/43404/psn-pdf
August 06, 2014 - 'Even now it makes me angry': health care students'
professionalism dilemma narratives.
August 6, 2014
Monrouxe L, Rees CE, Endacott R, et al. 'Even now it makes me angry': health care students'
professionalism dilemma narratives. Med Educ. 2014;48(5):502-17. doi:10.1111/medu.12377.
https://psnet.ahrq.gov/issue/ev…
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psnet.ahrq.gov/node/864862/psn-pdf
March 20, 2024 - Global Burden of Preventable Medication-related Harm in
Health Care: A Systematic Review.
March 20, 2024
Geneva, Switzerland: World Health Organization; 2023. ISBN: 9789240088887.
https://psnet.ahrq.gov/issue/global-burden-preventable-medication-related-harm-health-care-systematic-
review
The Medication Without H…
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psnet.ahrq.gov/node/48141/psn-pdf
July 24, 2019 - Evidence Brief: Implementation of High Reliability
Organization Principles.
July 24, 2019
Veazie S, Peterson K, Bourne D. Washington DC: United States Department of Veterans Affairs;
May 2019.
https://psnet.ahrq.gov/issue/evidence-brief-implementation-high-reliability-organization-principles
This brief evalu…
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psnet.ahrq.gov/node/34061/psn-pdf
January 04, 2017 - Patient Safety Leadership WalkRounds.
January 4, 2017
Frankel A, Graydon-Baker E, Neppl C, et al. Patient Safety Leadership WalkRounds. Jt Comm J Qual Saf.
2003;29(1). doi:10.1016/s1549-3741(03)29003-1.
https://psnet.ahrq.gov/issue/patient-safety-leadership-walkrounds
This study shares the concept of an interventi…
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psnet.ahrq.gov/node/44794/psn-pdf
May 21, 2019 - Medical Device Use Error: Root Cause Analysis.
May 21, 2019
Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790.
https://psnet.ahrq.gov/issue/medical-device-use-error-root-cause-analysis
Applying human factors engineering to examine mistakes associated with medical device use can lead …
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psnet.ahrq.gov/node/43967/psn-pdf
November 16, 2015 - Equipped: overcoming barriers to change to improve
quality of care (theories of change).
November 16, 2015
Lachman P, Runnacles J, Dudley J, et al. Equipped: overcoming barriers to change to improve quality of
care (theories of change). Arch Dis Child Educ Pract Ed. 2015;100(1):13-8. doi:10.1136/archdischild-2013-
…
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digital.ahrq.gov/organization/hancock-county-health-services
January 01, 2023 - Hancock County Health Services
Electronic Health Record Implementation for Continuum of Care in Rural Iowa - 2008
Principal Investigator
O'Brien, John
Project Name
Electronic Health Record Implementation for Continuum of Care in Rural Iowa
…
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digital.ahrq.gov/ahrq-funded-projects/achieving-individualized-precision-prevention-ipp-through-scalable/final-report
January 01, 2023 - Achieving Individualized Precision Prevention (IPP) through Scalable Infrastructure Employing the USPSTF Recommendations in Computable Form - Final Report
Citation
Friedman C. Achieving Individualized Precision Prevention (IPP) through Scalable Infrastructure Employing the USPSTF Recommendations in Co…
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digital.ahrq.gov/ahrq-funded-projects/health-information-technology-heart-failure-care/final-report
January 01, 2023 - Health Information Technology in Heart Failure Care - Final Report
Citation
Blecker S. Health Information Technology in Heart Failure Care - Final Report. (Prepared by the New York University School of Medicine under Grant No. K08 HS023683). Rockville, MD: Agency for Healthcare Research and Quality, 2…
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psnet.ahrq.gov/node/73178/psn-pdf
April 28, 2021 - Risk perception on the labour ward: a mixed methods
study.
April 28, 2021
McCarthy C, Meaney S, Rochford M, et al. Risk perception on the labour ward: a mixed methods study. J
Patient Saf Risk Manag. 2021;26(2):56-63. doi:10.1177/25160435211002428.
https://psnet.ahrq.gov/issue/risk-perception-labour-ward-mixed-met…
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psnet.ahrq.gov/node/46478/psn-pdf
March 27, 2018 - Promote a culture of safety with good catch reports.
March 27, 2018
Wallace SC, Mamrol C, Finley E. PA-PSRS Patient Saf Advis. September 2017;14.
https://psnet.ahrq.gov/issue/promote-culture-safety-good-catch-reports
Near misses or good catches present organizations with learning opportunities. Using data compariso…