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psnet.ahrq.gov/issue/cybersecurity-health-urgent-patient-safety-concern-we-can-learn-existing-patient-safety
October 28, 2020 - Commentary
Cybersecurity in health is an urgent patient safety concern: we can learn from existing patient safety improvement strategies to address it.
Citation Text:
O’Brien N, Ghafur S, Durkin M. Cybersecurity in health is an urgent patient safety concern: we can learn from existing pa…
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psnet.ahrq.gov/issue/influence-organizational-culture-climate-and-commitment-speaking-about-medical-errors
December 31, 2018 - Study
Emerging Classic
The influence of organizational culture, climate and commitment on speaking up about medical errors.
Citation Text:
Levine KJ, Carmody M, Silk KJ. The influence of organizational culture, climate and commitment on speaking up about medical…
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psnet.ahrq.gov/issue/effects-leadership-self-worth-inclusion-trust-and-psychological-safety-medical-error
March 30, 2022 - Study
The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error reporting.
Citation Text:
Brimhall KC, Tsai C-Y, Eckardt R, et al. The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error reporting. …
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psnet.ahrq.gov/issue/managing-hospitalized-patients-ambulatory-pumps-findings-ismp-survey-part-1
November 18, 2015 - Newspaper/Magazine Article
Managing hospitalized patients with ambulatory pumps: findings from an ISMP survey—Part 1.
Citation Text:
Managing hospitalized patients with ambulatory pumps: findings from an ISMP survey—Part 1. ISMP Medication Safety Alert! Acute care edition. November 19, 2…
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psnet.ahrq.gov/issue/how-does-hospital-quality-management-drive-quality-results-deepening-our-understanding
March 11, 2009 - Special or Theme Issue
How Does Hospital Quality Management Drive Quality? Results From the "Deepening Our Understanding of Quality Improvement (DUQuE)" Project.
Citation Text:
How Does Hospital Quality Management Drive Quality? Results From the "Deepening Our Understanding of Quality Im…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
January 29, 2020 - Delayed Diagnosis of Kidney Transplant Complications
Citation Text:
Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - Personal Health Literacy
August 30, 2023
Bakerjian D. Personal Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/personal-health-literacy
Originally published in July 2017 by researchers at the University of California, San Francisco. Updated in
August 2023 by Deb Bakerjian, PhD, RN, APRN, FAA…
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psnet.ahrq.gov/issue/factors-associated-missed-nursing-care-and-nurse-assessed-quality-care-during-covid-19
June 09, 2021 - Study
Factors associated with missed nursing care and nurse-assessed quality of care during the COVID-19 pandemic.
Citation Text:
Labrague LJ, Santos JAA, Fronda DC. Factors associated with missed nursing care and nurse‐assessed quality of care during the COVID‐19 pandemic. J Nurs Manag.…
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psnet.ahrq.gov/issue/self-reported-gaps-care-coordination-and-preventable-adverse-outcomes-among-older-adults
July 06, 2022 - Study
Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving home health care.
Citation Text:
Sterling MR, Lau J, Rajan M, et al. Self‐reported gaps in care coordination and preventable adverse outcomes among older adults receiving home heal…
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psnet.ahrq.gov/issue/peer-support-interprofessional-health-care-providers-aftermath-patient-safety-incidents-cross
September 22, 2021 - Study
Peer support by interprofessional health care providers in aftermath of patient safety incidents: a cross-sectional study.
Citation Text:
Vanhaecht K, Zeeman G, Schouten L, et al. Peer support by interprofessional health care providers in aftermath of patient safety incidents: a cr…
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psnet.ahrq.gov/issue/react-reframe-and-engage-establishing-receiver-mindset-more-effective-safety-negotiations
March 29, 2023 - Study
React, reframe and engage. Establishing a receiver mindset for more effective safety negotiations.
Citation Text:
Barlow M, Watson B, Morse K, et al. React, reframe and engage. Establishing a receiver mindset for more effective safety negotiations. J Health Organ Manag. 2024;38(7):…
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psnet.ahrq.gov/issue/longitudinal-study-clinical-peer-reviews-impact-quality-and-safety-us-hospitals
March 29, 2023 - Study
A longitudinal study of clinical peer review's impact on quality and safety in US hospitals.
Citation Text:
Edwards MT. A longitudinal study of clinical peer review's impact on quality and safety in U.S. hospitals. J Healthc Manag. 2013;58(5):369-85.
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psnet.ahrq.gov/node/34650/psn-pdf
April 21, 2015 - Human error: models and management.
April 21, 2015
Reason J. Human error: models and management. BMJ. 2000;320(7237):768-770.
https://psnet.ahrq.gov/issue/human-error-models-and-management
The author discusses concepts of human error, contrasting the person approach with a system approach in
understanding the diff…
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psnet.ahrq.gov/issue/high-risk-high-alert-medication-management-practices-regional-state-psychiatric-facility
January 06, 2017 - Study
High-risk, high-alert medication management practices in a regional state psychiatric facility.
Citation Text:
McKee J, Cleary S. High-Risk, High-Alert Medication Management Practices in a Regional State Psychiatric Facility. Hosp Pharm. 2007;42(4):323-330. doi:10.1310/hpj4204-323.…
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psnet.ahrq.gov/issue/multiple-failures-test-results-follow-patient-diagnosed-prostate-cancer-hampton-va-medical
July 26, 2023 - Book/Report
Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.
Citation Text:
Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in V…
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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/burnout-and-its-relationship-self-reported-quality-patient-care-and-adverse-events-during
August 25, 2021 - Study
Burnout and its relationship to self-reported quality of patient care and adverse events during COVID-19: a cross-sectional online survey among nurses.
Citation Text:
Kakemam E, Chegini Z, Rouhi A, et al. Burnout and its relationship to self‐reported quality of patient care and adv…
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psnet.ahrq.gov/issue/making-healthcare-safe-story-patient-safety-movement
January 20, 2021 - Book/Report
Making Healthcare Safe: The Story of the Patient Safety Movement.
Citation Text:
Making Healthcare Safe: The Story of the Patient Safety Movement. Leape LL. Cham, Switzerland: Springer Nature; 2021. ISBN: 9783030711252.
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psnet.ahrq.gov/issue/proposal-use-common-ground-exists-between-medical-and-legal-professions-promote-culture
December 15, 2021 - Commentary
A proposal to use common ground that exists between the medical and legal professions to promote a culture of safety.
Citation Text:
A proposal to use common ground that exists between the medical and legal professions to promote a culture of safety. Pegalis SE, 51 N.Y.L. SCH.…
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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…