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psnet.ahrq.gov/issue/covid-19-nursing-homes-cms-needs-continue-strengthen-oversight-infection-prevention-and
October 26, 2022 - Book/Report
COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control.
Citation Text:
COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control. Washington, DC: United States Government …
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psnet.ahrq.gov/issue/second-victim-casualties-and-how-physician-leaders-can-help
August 28, 2024 - Newspaper/Magazine Article
"Second victim" casualties and how physician leaders can help.
Citation Text:
MacLeod L. "Second victim" casualties and how physician leaders can help. Physician Exect. 2014;40(1):8-12.
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psnet.ahrq.gov/issue/digital-health-technology-specific-risks-medical-malpractice-liability
January 18, 2023 - Commentary
Digital health technology-specific risks for medical malpractice liability.
Citation Text:
Rowland SP, Fitzgerald JE, Lungren M, et al. Digital health technology-specific risks for medical malpractice liability. NPJ Digit Med. 2022;5(1):157. doi:10.1038/s41746-022-00698-3.
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psnet.ahrq.gov/issue/governing-safety-artificial-intelligence-healthcare
February 28, 2024 - Review
Emerging Classic
Governing the safety of artificial intelligence in healthcare.
Citation Text:
Macrae C. Governing the safety of artificial intelligence in healthcare. BMJ Qual Saf. 2019;28(6):495-498. doi:10.1136/bmjqs-2019-009484.
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psnet.ahrq.gov/issue/mitigating-hazards-through-continuing-design-birth-and-evolution-pediatric-intensive-care
April 06, 2011 - Commentary
Mitigating hazards through continuing design: the birth and evolution of a pediatric intensive care unit.
Citation Text:
Madsen P, Desai V, Roberts K, et al. Mitigating Hazards Through Continuing Design: The Birth and Evolution of a Pediatric Intensive Care Unit. Organizati…
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psnet.ahrq.gov/issue/teaching-quality-improvement
July 19, 2023 - Commentary
Teaching quality improvement.
Citation Text:
Murray ME, Douglas S, Girdley D, et al. Teaching quality improvement. J Nurs Educ. 2010;49(8):466-9. doi:10.3928/01484834-20100430-09.
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psnet.ahrq.gov/issue/creating-comprehensive-unit-based-approach-detecting-and-preventing-harm-neonatal-intensive
December 15, 2021 - Commentary
Creating a comprehensive, unit-based approach to detecting and preventing harm in the neonatal intensive care unit.
Citation Text:
Creating a comprehensive, unit-based approach to detecting and preventing harm in the neonatal intensive care unit. Sedlock EW, Ottosen M, Nether …
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psnet.ahrq.gov/issue/teaching-nurses-make-clinical-judgments-ensure-patient-safety
August 17, 2022 - Commentary
Teaching nurses to make clinical judgments that ensure patient safety.
Citation Text:
Billings DM. Teaching Nurses to Make Clinical Judgments That Ensure Patient Safety. J Contin Educ Nurs. 2019;50(7):300-302. doi:10.3928/00220124-20190612-04.
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psnet.ahrq.gov/issue/view-cockpit-what-airline-industry-can-teach-us-about-patient-safety
January 08, 2020 - Commentary
View from the cockpit: what the airline industry can teach us about patient safety.
Citation Text:
Doucette JN. View from the cockpit: what the airline industry can teach us about patient safety. Nursing (Brux). 2006;36(11):50-53.
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psnet.ahrq.gov/issue/content-and-context-change-shift-report-medical-and-surgical-units
September 24, 2016 - Study
The content and context of change of shift report on medical and surgical units.
Citation Text:
Staggers N, Jennings BM. The content and context of change of shift report on medical and surgical units. J Nurs Adm. 2009;39(9):393-8. doi:10.1097/NNA.0b013e3181b3b63a.
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psnet.ahrq.gov/issue/improving-patient-safety-through-simulation-training-anesthesiology-where-are-we
October 13, 2018 - Review
Improving patient safety through simulation training in anesthesiology: where are we?
Citation Text:
Green M, Tariq R, Green P. Improving Patient Safety through Simulation Training in Anesthesiology: Where Are We? Anesthesiol Res Pract. 2016;2016:4237523. doi:10.1155/2016/4237523.…
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psnet.ahrq.gov/issue/safety-mind-mental-health-services-and-patient-safety
August 07, 2018 - Book/Report
With Safety in Mind: Mental Health Services and Patient Safety.
Citation Text:
With Safety in Mind: Mental Health Services and Patient Safety. Scobie S, Minghella E, Dale C, et al. London, UK: National Patient Safety Agency; 2006.
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psnet.ahrq.gov/issue/barriers-and-facilitators-communicating-nursing-errors-long-term-care-settings
March 27, 2018 - Study
Barriers and facilitators to communicating nursing errors in long-term care settings.
Citation Text:
Wagner LM, Damianakis T, Pho L, et al. Barriers and facilitators to communicating nursing errors in long-term care settings. J Patient Saf. 2013;9(1):1-7. doi:10.1097/PTS.0b013e31…
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psnet.ahrq.gov/issue/health-care-provider-use-private-sector-internal-error-reporting-systems
May 29, 2019 - Study
Health care provider use of private sector internal error-reporting systems.
Citation Text:
Roumm AR, Sciamanna CN, Nash DB. Health care provider use of private sector internal error-reporting systems. Am J Med Qual. 2005;20(6):304-12.
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psnet.ahrq.gov/issue/need-risk-profiling-patient-safety
August 08, 2010 - Commentary
The need for risk profiling in patient safety.
Citation Text:
Donaldson LJ, Noble DJ. The need for risk profiling in patient safety. J Patient Saf. 2010;6(3):125-7. doi:10.1097/PTS.0b013e3181ed73a3.
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psnet.ahrq.gov/issue/agreement-between-patient-reported-symptoms-and-their-documentation-medical-record
November 09, 2022 - Study
Agreement between patient-reported symptoms and their documentation in the medical record.
Citation Text:
Pakhomov S, Jacobsen SJ, Chute CG, et al. Agreement between patient-reported symptoms and their documentation in the medical record. Am J Manag Care. 2008;14(8):530-539.
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psnet.ahrq.gov/issue/fixing-healthcare-inside-today
February 28, 2011 - Commentary
Classic
Fixing healthcare from the inside, today.
Citation Text:
Spear SJ. Fixing health care from the inside, today. Harv Bus Rev. 2005;83(9):78-91, 158.
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psnet.ahrq.gov/issue/medication-related-clinical-decision-support-computerized-provider-order-entry-systems-review
March 11, 2011 - Review
Medication-related clinical decision support in computerized provider order entry systems: a review.
Citation Text:
Kuperman GJ, Bobb A, Payne TH, et al. Medication-related clinical decision support in computerized provider order entry systems: a review. J Am Med Inform Assoc. 2…
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psnet.ahrq.gov/issue/computer-visualisation-patient-safety-primary-care-systems-approach-adapted-management
October 06, 2011 - Commentary
Computer visualisation of patient safety in primary care: a systems approach adapted from management science and engineering.
Citation Text:
Singh R, Singh A, Fox C, et al. Computer visualisation of patient safety in primary care: a systems approach adapted from management sci…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/mcc-summit/mcc-summit-arlene.pdf
November 17, 2020 - Transforming Care for People Living with Multiple Chronic Conditions
Transforming Care for People Living with
Multiple Chronic Conditions
Arlene Bierman, M.D., M.S.
Director, Center for Evidence and Practice Improvement
Agency for Healthcare Research and Quality
November 17, 2020
Why MCC?
• Common, Costly
• H…