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  1. Risk mitigation in large scale systems: lessons from high reliability organizations. | PSNet

    psnet.ahrq.gov/issue/risk-mitigation-large-scale-systems-lessons-high-reliability-organizations
    January 30, 2019 - Commentary Classic Risk mitigation in large scale systems: lessons from high reliability organizations. Citation Text: Risk mitigation in large scale systems: lessons from high reliability organizations. Grabowski M, Roberts K. Calif Manag Rev. 1997;39(4):152-16…

  2. The Future of Emergency Care in the United States Health System. | PSNet

    psnet.ahrq.gov/issue/future-emergency-care-united-states-health-system
    June 16, 2012 - Book/Report The Future of Emergency Care in the United States Health System. Citation Text: The Future of Emergency Care in the United States Health System. Institute of Medicine. Washington DC; National Academies Press: 2007. Copy Citation Save Save to your l…

  3. The underappreciated role of habit in highly reliable healthcare. | PSNet

    psnet.ahrq.gov/issue/underappreciated-role-habit-highly-reliable-healthcare
    April 25, 2016 - Commentary The underappreciated role of habit in highly reliable healthcare. Citation Text: Vogus TJ, Hilligoss B. The underappreciated role of habit in highly reliable healthcare. BMJ Qual Saf. 2016;25(3):141-6. doi:10.1136/bmjqs-2015-004512. Copy Citation Format: DOI Goog…

  4. Fostering transparency in outcomes, quality, safety, and costs. | PSNet

    psnet.ahrq.gov/issue/fostering-transparency-outcomes-quality-safety-and-costs
    January 29, 2015 - Commentary Fostering transparency in outcomes, quality, safety, and costs. Citation Text: Austin M, McGlynn EA, Pronovost P. Fostering Transparency in Outcomes, Quality, Safety, and Costs. JAMA. 2016;316(16):1661-1662. doi:10.1001/jama.2016.14039. Copy Citation Format: DOI …

  5. Digital health technology-specific risks for medical malpractice liability. | PSNet

    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. C…

  6. Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2012. | PSNet

    psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-safety-2012
    November 02, 2012 - Book/Report Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2012. Citation Text: Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2012. Oakbrook Terrace, IL: The Joint Commission; September 2012. C…

  7. Ambiguity and workarounds as contributors to medical error. | PSNet

    psnet.ahrq.gov/issue/ambiguity-and-workarounds-contributors-medical-error
    December 23, 2008 - Commentary Ambiguity and workarounds as contributors to medical error. Citation Text: Spear SJ, Schmidhofer M. Ambiguity and workarounds as contributors to medical error. Ann Intern Med. 2005;142(8):627-630. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XM…

  8. Implementing patient safety and quality improvement in dermatology. | PSNet

    psnet.ahrq.gov/issue/implementing-patient-safety-and-quality-improvement-dermatology
    September 30, 2015 - Commentary Implementing patient safety and quality improvement in dermatology. Citation Text: Implementing patient safety and quality improvement in dermatology. Marsch A, Khodosh R, Porter M, et al. J Am Acad Dermatol. 2023;89(4):641-54; 57-67. Copy Citation Save …

  9. Building cultures of high reliability: lessons from the high reliability organization paradigm. | PSNet

    psnet.ahrq.gov/issue/building-cultures-high-reliability-lessons-high-reliability-organization-paradigm
    September 05, 2018 - Review Building cultures of high reliability: lessons from the high reliability organization paradigm. Citation Text: Sutcliffe KM. Building cultures of high reliability: lessons from the high reliability organization paradigm. Anesthesiol Clin. 2023;41(4):707-717. doi:10.1016/j.anclin.2…

  10. Intravenous infusion safety technology: return on investment. | PSNet

    psnet.ahrq.gov/issue/intravenous-infusion-safety-technology-return-investment
    October 29, 2017 - Study Intravenous infusion safety technology: return on investment. Citation Text: Danello SH, Maddox RR, Schaack GJ. Intravenous Infusion Safety Technology: Return on Investment. Hosp Pharm. 2010;44(8):680-688. doi:10.1310/hpj4408-680. Copy Citation Format: DOI Google Scho…

  11. Examination of maternal near-miss experiences in the hospital setting among Black women in the United States. | PSNet

    psnet.ahrq.gov/issue/examination-maternal-near-miss-experiences-hospital-setting-among-black-women-united-states
    August 26, 2020 - Study Examination of maternal near-miss experiences in the hospital setting among Black women in the United States. Citation Text: Byrd TE, Ingram LA, Okpara N. Examination of maternal near-miss experiences in the hospital setting among Black women in the United States. Womens Health (Lo…

  12. A state-of-the-art review of speaking up in healthcare. | PSNet

    psnet.ahrq.gov/issue/state-art-review-speaking-healthcare
    October 13, 2021 - Review A state-of-the-art review of speaking up in healthcare. Citation Text: Violato E. A state-of-the-art review of speaking up in healthcare. Adv Health Sci Educ Theory Pract. 2022;27(4):1177-1194. doi:10.1007/s10459-022-10124-8. Copy Citation Format: DOI Google Scholar …

  13. Burnout Among Health Care Professionals. A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care. | PSNet

    psnet.ahrq.gov/issue/burnout-among-health-care-professionals-call-explore-and-address-underrecognized-threat-safe
    November 11, 2020 - Book/Report Burnout Among Health Care Professionals. A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care. Citation Text: Burnout Among Health Care Professionals. A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care. Dyrbye …

  14. The limits of checklists: handoff and narrative thinking. | PSNet

    psnet.ahrq.gov/issue/limits-checklists-handoff-and-narrative-thinking
    July 01, 2017 - Commentary The limits of checklists: handoff and narrative thinking. Citation Text: Hilligoss B, Moffatt-Bruce SD. The limits of checklists: handoff and narrative thinking. BMJ Qual Saf. 2014;23(7):528-33. doi:10.1136/bmjqs-2013-002705. Copy Citation Format: DOI Google Scho…

  15. Coaching the debriefer: peer coaching to improve debriefing quality in simulation programs. | PSNet

    psnet.ahrq.gov/issue/coaching-debriefer-peer-coaching-improve-debriefing-quality-simulation-programs
    July 31, 2019 - Commentary Coaching the debriefer: peer coaching to improve debriefing quality in simulation programs. Citation Text: Cheng A, Grant V, Huffman J, et al. Coaching the Debriefer: Peer Coaching to Improve Debriefing Quality in Simulation Programs. Simul Healthc. 2017;12(5):319-325. doi:10.…

  16. SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. | PSNet

    psnet.ahrq.gov/issue/seips-20-human-factors-framework-studying-and-improving-work-healthcare-professionals-and
    February 16, 2022 - Commentary SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. Citation Text: Holden RJ, Carayon P, Gurses AP, et al. SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and p…

  17. Five strategies for clinicians to advance diagnostic excellence. | PSNet

    psnet.ahrq.gov/issue/five-strategies-clinicians-advance-diagnostic-excellence
    June 22, 2022 - Commentary Five strategies for clinicians to advance diagnostic excellence. Citation Text: Singh H, Connor DM, Dhaliwal G. Five strategies for clinicians to advance diagnostic excellence. BMJ. 2022;376:e068044. doi:10.1136/bmj-2021-068044. Copy Citation Format: DOI Google S…

  18. Professional values and reported behaviours of doctors in the USA and UK: quantitative survey. | PSNet

    psnet.ahrq.gov/issue/professional-values-and-reported-behaviours-doctors-usa-and-uk-quantitative-survey
    February 17, 2011 - Study Professional values and reported behaviours of doctors in the USA and UK: quantitative survey. Citation Text: Roland M, Rao SR, Sibbald B, et al. Professional values and reported behaviours of doctors in the USA and UK: quantitative survey. BMJ Qual Saf. 2011;20(6):515-21. doi:10…

  19. 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 …

  20. Engagement of leadership in quality improvement initiatives: executive quality improvement survey results. | PSNet

    psnet.ahrq.gov/issue/engagement-leadership-quality-improvement-initiatives-executive-quality-improvement-survey
    October 04, 2006 - Study Engagement of leadership in quality improvement initiatives: executive quality improvement survey results. Citation Text: Engagement of leadership in quality improvement initiatives: executive quality improvement survey results. Vaughn T, Koepke M, Kroch E, et al. J Patient Saf…
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