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psnet.ahrq.gov/issue/patient-mortality-during-unannounced-accreditation-surveys-us-hospitals
August 03, 2022 - A past PSNet interview with the president of The Joint Commission discussed his role in the organization
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psnet.ahrq.gov/issue/what-can-we-learn-depth-analysis-human-errors-resulting-diagnostic-errors-emergency
June 08, 2022 - Analysis of incident reports from a patient safety organization.
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psnet.ahrq.gov/issue/impact-medical-mistakes-navigating-work-family-boundaries-physicians-and-their-families
January 23, 2019 - June 11, 2008
Just Culture: Restoring Trust and Accountability in Your Organization, … October 17, 2012
Evidence Brief: Implementation of High Reliability Organization Principles
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psnet.ahrq.gov/issue/use-bar-code-technology-medication-administration
January 23, 2019 - June 11, 2008
Just Culture: Restoring Trust and Accountability in Your Organization, … October 17, 2012
Evidence Brief: Implementation of High Reliability Organization Principles
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psnet.ahrq.gov/primer/handoffs-and-signouts
October 18, 2023 - Handoffs and Signouts
Citation Text:
Handoffs and Signouts. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/primer/handoffs
October 18, 2023 - Handoffs
Citation Text:
Handoffs and Signouts. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/866343/psn-pdf
December 31, 2024 - Mismanagement of Acute Decompensated Heart Failure
with Hypertensive Emergency
December 31, 2024
Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive
Emergency. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hyperte…
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psnet.ahrq.gov/node/49727/psn-pdf
March 01, 2015 - ) Both the College of American Pathologists Laboratory Accreditation Program and the
International Organization … International Organization for Standardization.
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psnet.ahrq.gov/node/49791/psn-pdf
April 01, 2017 - involving all team members.(9) The importance of a team time-out is also
emphasized in the World Health Organization … preventing wrong-site errors includes The Joint Commission
Universal Protocol and the World Health Organization
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psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd
February 01, 2019 - main academic hospital becomes more tertiary and quaternary every day, and we're partnering with other organizations … Curricula
February 1, 2019
Perspective
We will never transform the prevailing system of an organization … They also need to embrace new skills and habits, and teams and organizations need to adopt a new way
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psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding
November 25, 2020 - providers have scrambled to find solutions to the growing burden of wall time. 28,29 Some pre-hospital organizations … shown promise in local studies, but have not been evaluated rigorously and at scale:
Pre-hospital organizations … Requirements for a Determination that a Facility or an Organization has Provider-based Status. 42 C.F.R
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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - It is clear that for many residents and the patients they serve, the organization of training practices
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psnet.ahrq.gov/issue/patient-and-family-advisory-council-leaders-guide-diagnostic-quality-and-safety
September 16, 2020 - Book/Report
Patient and Family Advisory Council Leader's Guide for Diagnostic Quality and Safety.
Citation Text:
Patient and Family Advisory Council Leader's Guide for Diagnostic Quality and Safety. Chicago, IL; Society to Improve Diagnosis in Medicine: August 2020.
…
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psnet.ahrq.gov/issue/surgical-innovation-new-techniques-and-technologies-guide-good-practice
April 10, 2019 - Book/Report
Surgical Innovation, New Techniques and Technologies: A Guide to Good Practice.
Citation Text:
Surgical Innovation, New Techniques and Technologies: A Guide to Good Practice. London, UK: Royal College of Surgeons of England; 2019.
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psnet.ahrq.gov/issue/distributing-cognition-icu-handoffs-conform-grices-maxims
May 09, 2015 - Image/Poster
Distributing Cognition: ICU Handoffs Conform to Grice's Maxims.
Citation Text:
Distributing Cognition: ICU Handoffs Conform to Grice's Maxims. Brandwijk M; Nemeth C; O'Conner M; Kahana M; Cook RI
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psnet.ahrq.gov/issue/surgical-black-box-could-reduce-errors
June 04, 2014 - Newspaper/Magazine Article
Surgical 'black box' could reduce errors.
Citation Text:
Surgical 'black box' could reduce errors. Sathya C. CNN. August 22, 2014.
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psnet.ahrq.gov/issue/improving-diagnosis-and-treatment-maternal-sepsis
September 22, 2021 - Toolkit
Improving Diagnosis and Treatment of Maternal Sepsis.
Citation Text:
Improving Diagnosis and Treatment of Maternal Sepsis. Stanford, CA; California Maternal Quality Care Collaborative: July 1, 2022.
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psnet.ahrq.gov/issue/wrong-foot-and-other-tales-surgical-error
January 18, 2023 - Newspaper/Magazine Article
The wrong foot, and other tales of surgical error.
Citation Text:
The wrong foot, and other tales of surgical error. Altman LK. New York Times. December 11, 2001;1:1.
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psnet.ahrq.gov/issue/patient-safety-improvement-act-2020
February 12, 2020 - Government Resource
Patient Safety Improvement Act of 2020.
Citation Text:
Patient Safety Improvement Act of 2020. SB 3380. 116th Congress (2020).
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psnet.ahrq.gov/issue/making-hospitals-safe-people-diabetes
November 14, 2018 - Book/Report
Making Hospitals Safe for People With Diabetes.
Citation Text:
Making Hospitals Safe for People With Diabetes. Watts E, Rayman G. Diabetes UK. London, UK; 2018.
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