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psnet.ahrq.gov/issue/using-medical-malpractice-closed-claims-data-reduce-surgical-risk-and-improve-patient-safety
December 01, 2010 - Commentary
Using medical malpractice closed claims data to reduce surgical risk and improve patient safety.
Citation Text:
Manuel BM, Greenwald LM. Using medical malpractice closed claims data to reduce surgical risk and improve patient safety. Bull Am Coll Surg. 2007;92(3):27-30.
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psnet.ahrq.gov/issue/effective-followership-standardized-algorithm-resolve-clinical-conflicts-and-improve-teamwork
March 13, 2013 - Commentary
Effective followership: a standardized algorithm to resolve clinical conflicts and improve teamwork.
Citation Text:
Sculli GL, Fore AM, Sine DM, et al. Effective followership: A standardized algorithm to resolve clinical conflicts and improve teamwork. J Healthc Risk Manag. 20…
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psnet.ahrq.gov/issue/swiss-cheese-model
March 27, 2005 - Image/Poster
Swiss Cheese Model.
Citation Text:
Swiss Cheese Model. Adapted from: Reason JT. Managing the Risks of Organizational Accidents. Aldershot, Hants, England: Ashgate: 1997.
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psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - Acute Respiratory Arrest in Pregnancy
Citation Text:
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/issue/what-influences-sustainment-and-nonsustainment-facilitation-activities-implementation
April 17, 2017 - Study
What influences sustainment and nonsustainment of facilitation activities in implementation? Analysis of organizational factors in hospitals implementing TeamSTEPPS.
Citation Text:
Baloh J, Zhu X, Ward MM. What influences sustainment and nonsustainment of facilitation activities in…
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psnet.ahrq.gov/web-mm/forgotten-drip
April 01, 2014 - The Forgotten Drip
Citation Text:
Josephson AS. The Forgotten Drip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/issue/patient-participation-patient-safety-exploration-promoting-factors
October 15, 2016 - Study
Emerging Classic
Patient participation in patient safety—an exploration of promoting factors.
Citation Text:
Sahlström M, Partanen P, Azimirad M, et al. Patient participation in patient safety-An exploration of promoting factors. J Nurs Manag. 2019;27(1):8…
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psnet.ahrq.gov/issue/fdasia-health-it-report-proposed-strategy-and-recommendations-risk-based-framework
June 29, 2016 - Government Resource
FDASIA Health IT Report: Proposed Strategy and Recommendations for a Risk-Based Framework.
Citation Text:
FDASIA Health IT Report: Proposed Strategy and Recommendations for a Risk-Based Framework. Washington, DC: Office of the National Coordinator for Health Informati…
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psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
December 04, 2016 - Variations in how ICU nurses manage vasoactive medications and identification of practice variations
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psnet.ahrq.gov/node/46349/psn-pdf
August 16, 2017 - Health Literacy Tools for Providers of Medication Therapy
Management.
August 16, 2017
Rockville, MD: Agency for Healthcare Research and Quality; July 2017.
https://psnet.ahrq.gov/issue/health-literacy-tools-providers-medication-therapy-management
Health literacy is important for effective care communications and s…
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psnet.ahrq.gov/node/39960/psn-pdf
September 19, 2016 - Respectful Management of Serious Clinical Adverse
Events. Second Edition.
September 19, 2016
Conway J, Federico F, Stewart K, Campbell MJ. Cambridge, MA: Institute for Healthcare Improvement;
2011.
https://psnet.ahrq.gov/issue/respectful-management-serious-clinical-adverse-events-second-edition
This white paper e…
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psnet.ahrq.gov/web-mm/who-nose-where-airway
May 01, 2016 - Who Nose Where the Airway Is?
Citation Text:
Lee CR. Who Nose Where the Airway Is?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/Information/Editor
Browse Author Resources
Meet PSNet's Editorial Team The PSNet editorial team is committed to producing the highest quality patient safety content. The team brings a wealth of experience and deep subject matter expertise in the field, ensuring that PSNet content is accurate, reliable, and…
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psnet.ahrq.gov/issue/safety-implications-missed-test-results-hospitalised-patients-systematic-review
November 26, 2014 - Review
Classic
The safety implications of missed test results for hospitalised patients: a systematic review.
Citation Text:
Callen J, Georgiou A, Li J, et al. The safety implications of missed test results for hospitalised patients: a systematic review. BMJ Q…
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psnet.ahrq.gov/issue/stay-connected-faqs-about-small-bore-connectors-and-tubing-misconnections
March 12, 2016 - Book/Report
Stay Connected: FAQs about Small-Bore Connectors and Tubing Misconnections.
Citation Text:
Stay Connected: FAQs about Small-Bore Connectors and Tubing Misconnections. Arlington, VA: Association for the Advancement of Medical Instrumentation; October 2013.
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psnet.ahrq.gov/issue/organisation-memory-report-expert-group-learning-adverse-events-nhs-chaired-chief-medical
June 12, 2013 - Book/Report
Classic
An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS Chaired by the Chief Medical Officer.
Citation Text:
An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events …
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psnet.ahrq.gov/issue/courage-speak-out-study-describing-nurses-attitudes-report-unsafe-practices-patient-care
April 24, 2018 - Study
The courage to speak out: a study describing nurses' attitudes to report unsafe practices in patient care.
Citation Text:
Cole DA, Bersick E, Skarbek A, et al. The courage to speak out: A study describing nurses' attitudes to report unsafe practices in patient care. J Nurs Manag. 2…
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psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
March 01, 2012 - Conversation with…John Banja, PhD
February 1, 2006
A mediation skills model to manage
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psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
December 01, 2006 - May 1, 2011
Perspective
How to Identify and Manage