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Case study: identifying potential problems at the human/technical interface in complex clinical systems. | PSNet

psnet.ahrq.gov/issue/case-study-identifying-potential-problems-humantechnical-interface-complex-clinical-systems

July 22, 2009 - Commentary Case study: identifying potential problems at the human/technical interface in complex clinical systems. Citation Text: Caudill-Slosberg M, Weeks WB. Case study: identifying potential problems at the human/technical interface in complex clinical systems. Am J Med Qual. 2005;…

Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. | PSNet

psnet.ahrq.gov/issue/best-care-lower-cost-path-continuously-learning-health-care-america

July 08, 2016 - Book/Report Classic Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Citation Text: Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds. Committe…

The interrelationship of isolation precautions and adverse events in an acute care facility. | PSNet

psnet.ahrq.gov/issue/interrelationship-isolation-precautions-and-adverse-events-acute-care-facility

September 24, 2010 - Study The interrelationship of isolation precautions and adverse events in an acute care facility. Citation Text: Spence MR, McQuaid M. The interrelationship of isolation precautions and adverse events in an acute care facility. Am J Infect Control. 2011;39(2):154-155. doi:10.1016/j.aj…

Medical Problem Solving: An Analysis of Clinical Reasoning. | PSNet

psnet.ahrq.gov/issue/medical-problem-solving-analysis-clinical-reasoning

July 18, 2018 - Book/Report Classic Medical Problem Solving: An Analysis of Clinical Reasoning. Citation Text: Medical Problem Solving: An Analysis of Clinical Reasoning. Elstein AS, ed. Cambridge, MA: Harvard University Press; 1978. ISBN: 9780674561250. Copy Citation …

AHRQ Communication and Optimal Resolution (CANDOR) Toolkit. | PSNet

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May 25, 2016 - Toolkit AHRQ Communication and Optimal Resolution (CANDOR) Toolkit. Citation Text: AHRQ Communication and Optimal Resolution (CANDOR) Toolkit. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. Copy Citation Save Save to your library Print …

The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. | PSNet

psnet.ahrq.gov/issue/challenger-launch-decision-risky-technology-culture-and-deviance-nasa

November 18, 2015 - Book/Report Classic The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. Citation Text: The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. Vaughan D. Chicago, IL: University of Chicago Press; 1996. ISBN…

CMS changes in reimbursement for HAIs: setting a research agenda. | PSNet

psnet.ahrq.gov/issue/cms-changes-reimbursement-hais-setting-research-agenda

May 03, 2018 - Commentary CMS changes in reimbursement for HAIs: setting a research agenda. Citation Text: Stone PW, Glied SA, McNair PD, et al. CMS changes in reimbursement for HAIs: setting a research agenda. Med Care. 2010;48(5):433-9. doi:10.1097/MLR.0b013e3181d5fb3f. Copy Citation Format: …

Driving improvement in patient care: lessons from Toyota. | PSNet

psnet.ahrq.gov/issue/driving-improvement-patient-care-lessons-toyota

September 24, 2016 - Study Classic Driving improvement in patient care: lessons from Toyota. Citation Text: Thompson DN, Wolf GA, Spear SJ. Driving improvement in patient care: lessons from Toyota. J Nurs Adm. 2003;33(11):585-595. Copy Citation Format: Google Scholar …

In Conversation with…William B. Munier, MD, MBA | PSNet

psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba

July 01, 2011 - In Conversation with…William B. Munier, MD, MBA July 1, 2011 Also Read an Essay Citation Text: In Conversation with…William B. Munier, MD, MBA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…

Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience. | PSNet

psnet.ahrq.gov/issue/errors-administration-intravenous-medications-hospital-and-role-correct-procedures-and-nurse

September 26, 2016 - Study Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience. Citation Text: Westbrook JI, Rob MI, Woods A, et al. Errors in the administration of intravenous medications in hospital and the role of correct procedures a…

The influence that electronic prescribing has on medication errors and preventable adverse drug events: an interrupted time-series study. | PSNet

psnet.ahrq.gov/issue/influence-electronic-prescribing-has-medication-errors-and-preventable-adverse-drug-events

August 18, 2010 - Study The influence that electronic prescribing has on medication errors and preventable adverse drug events: an interrupted time-series study. Citation Text: van Doormaal J, van den Bemt PMLA, Zaal RJ, et al. The influence that electronic prescribing has on medication errors and preve…

Afraid in the hospital: parental concern for errors during a child's hospitalization. | PSNet

psnet.ahrq.gov/issue/afraid-hospital-parental-concern-errors-during-childs-hospitalization

April 21, 2011 - Study Classic Afraid in the hospital: parental concern for errors during a child's hospitalization. Citation Text: Tarini BA, Lozano P, Christakis DA. Afraid in the hospital: parental concern for errors during a child's hospitalization. J Hosp Med. 2009;41(9):…

Normal Accidents: Living with High-Risk Technologies. | PSNet

psnet.ahrq.gov/issue/normal-accidents-living-high-risk-technologies

March 06, 2005 - Book/Report Classic Normal Accidents: Living with High-Risk Technologies. Citation Text: Normal Accidents: Living with High-Risk Technologies. Perrow C. Princeton NJ: Princeton University Press; 1999. Copy Citation Save Save to you…

Health care worker fatigue and patient safety. | PSNet

psnet.ahrq.gov/issue/health-care-worker-fatigue-and-patient-safety

December 23, 2016 - Sentinel Event Alerts Health care worker fatigue and patient safety. Citation Text: Health care worker fatigue and patient safety. Sentinel Event Alert. December 14, 2011;(48):1-4. (addendum May 14, 2018). Copy Citation Save Save to your library Print Do…

Internal medicine trainees' views of training adequacy and duty hours restrictions in 2009. | PSNet

psnet.ahrq.gov/issue/internal-medicine-trainees-views-training-adequacy-and-duty-hours-restrictions-2009

August 20, 2018 - Study Internal medicine trainees' views of training adequacy and duty hours restrictions in 2009. Citation Text: Shea JA, Weissman A, McKinney S, et al. Internal medicine trainees' views of training adequacy and duty hours restrictions in 2009. Acad Med. 2012;87(7):889-94. doi:10.1097/AC…

Tackling communication barriers between long-term care facility and emergency department transfers to improve medication safety in older adults. | PSNet

psnet.ahrq.gov/issue/tackling-communication-barriers-between-long-term-care-facility-and-emergency-department

August 02, 2017 - Commentary Tackling communication barriers between long-term care facility and emergency department transfers to improve medication safety in older adults. Citation Text: Callinan SM, Brandt NJ. Tackling communication barriers between long-term care facility and emergency department tran…

Impact of a clinical decision support system for high-alert medications on the prevention of prescription errors. | PSNet

psnet.ahrq.gov/issue/impact-clinical-decision-support-system-high-alert-medications-prevention-prescription-errors

May 10, 2017 - Study Impact of a clinical decision support system for high-alert medications on the prevention of prescription errors. Citation Text: Lee JH, Han H, Ock M, et al. Impact of a clinical decision support system for high-alert medications on the prevention of prescription errors. Int J Med …

Organisational readiness: exploring the preconditions for success in organisation-wide patient safety improvement programmes. | PSNet

psnet.ahrq.gov/issue/organisational-readiness-exploring-preconditions-success-organisation-wide-patient-safety

February 01, 2011 - Study Organisational readiness: exploring the preconditions for success in organisation-wide patient safety improvement programmes. Citation Text: Burnett S, Benn J, Pinto A, et al. Organisational readiness: exploring the preconditions for success in organisation-wide patient safety im…

Implementation, Adoption, and Scaling Workgroup: Landscape Assessment on the Use of Artificial Intelligence to Scale PC CDS. | PSNet

psnet.ahrq.gov/issue/implementation-adoption-and-scaling-workgroup-landscape-assessment-use-artificial

December 01, 2017 - Book/Report Implementation, Adoption, and Scaling Workgroup: Landscape Assessment on the Use of Artificial Intelligence to Scale PC CDS. Citation Text: Kawamoto K, Greysen SR, Heaney-Huls K, et al. Implementation, Adoption, And Scaling Workgroup: Landscape Assessment On The Use Of Artifi…

Nurse staffing in hospitals: is there a business case for quality? | PSNet

psnet.ahrq.gov/issue/nurse-staffing-hospitals-there-business-case-quality

February 18, 2011 - Study Classic Nurse staffing in hospitals: is there a business case for quality? Citation Text: Needleman J, Buerhaus P, Stewart M, et al. Nurse staffing in hospitals: is there a business case for quality? Health Aff (Millwood). 2006;25(1):204-11. Copy Citat…

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