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psnet.ahrq.gov/issue/intervention-increase-situational-awareness-and-culture-mutual-care-foco-and-its-effects
November 21, 2021 - Study
An intervention to increase situational awareness and the Culture of Mutual Care (Foco) and its effects during COVID-19 pandemic: a randomized controlled trial and qualitative analysis.
Citation Text:
Kozasa EH, Lacerda SS, Polissici MA, et al. An Intervention to Increase Situation…
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psnet.ahrq.gov/issue/association-between-handover-anesthesiology-care-and-1-year-mortality-among-adults-undergoing
June 08, 2022 - Study
Association between handover of anesthesiology care and 1-year mortality among adults undergoing cardiac surgery.
Citation Text:
Sun LY, Jones PM, Wijeysundera DN, et al. Association between handover of anesthesiology care and 1-year mortality among adults undergoing cardiac surger…
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psnet.ahrq.gov/issue/communication-interdisciplinary-teams-exploring-closed-loop-communication-during-situ-trauma
July 19, 2023 - Study
Communication in interdisciplinary teams: exploring closed-loop communication during in situ trauma team training.
Citation Text:
Härgestam M, Lindkvist M, Brulin C, et al. Communication in interdisciplinary teams: exploring closed-loop communication during in situ trauma team tra…
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psnet.ahrq.gov/issue/outbreak-investigation-covid-19-among-residents-and-staff-independent-and-assisted-living
October 19, 2022 - Study
Outbreak investigation of COVID-19 among residents and staff of an independent and assisted living community for older adults in Seattle, Washington.
Citation Text:
Roxby AC, Greninger AL, Hatfield KM, et al. Outbreak investigation of COVID-19 among residents and staff of an indepe…
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psnet.ahrq.gov/issue/against-silence-development-and-first-results-patient-survey-assess-experiences-safety
March 24, 2021 - December 16, 2020
A high-reliability organization framework for health care: a multiyear … April 2, 2014
Evidence-based organization and patient safety strategies in European hospitals
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psnet.ahrq.gov/issue/incidence-adverse-events-swedish-hospitals-retrospective-medical-record-review-study
August 05, 2009 - Self-Reported Learning (SRL), a voluntary incident reporting system experience within a large health care organization … April 2, 2014
Evidence-based organization and patient safety strategies in European hospitals
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psnet.ahrq.gov/issue/team-resource-management-and-patient-safety-team-focused-approach-clinical-governance
August 26, 2015 - December 10, 2014
Towards an organization with a memory: exploring the organizational … November 25, 2020
A high-reliability organization framework for health care: a multiyear
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psnet.ahrq.gov/issue/patient-safety-checklist-keys-successful-implementation
July 19, 2023 - February 1, 2023
Factors causing variation in World Health Organization surgical safety … systematic review of interventions used to enhance implementation of and compliance with the World Health Organization
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psnet.ahrq.gov/node/865412/psn-pdf
March 27, 2024 - Delayed Diagnosis and Treatment of Systemic Lupus
Erythematosus with a Psychiatric Presentation
March 27, 2024
Bourgeois JA, Xiong G. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a
Psychiatric Presentation. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatmen…
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psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures
Citation Text:
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
January 01, 2016 - The World Health Organization (WHO) and The Joint Commission have recommended strategies for reducing … World Health Organization, Joint Commission International, Joint Commission; May 2007.
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psnet.ahrq.gov/node/49568/psn-pdf
September 01, 2008 - While the AAP and World Health Organization recommend
exclusive breastfeeding for 6 months, only 11% … Geneva, Switzerland: World Health
Organization, Division of Child Health and Development; 1998.
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psnet.ahrq.gov/node/73202/psn-pdf
April 28, 2021 - It is important
to note that the American Academy of Pediatrics, the CDC, and the World Health Organization … an urgent national warning in early November 2020 cautioning about this error.13 The
World Health Organization … World Health Organization.
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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - The wisdom of teams: creating the high performance organization. … training of nurses on high-risk unit and for high-risk procedures may be inadequate
B
Organization … goal
Every team member shares and understands the short- and long-term goals of the team and the organization
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psnet.ahrq.gov/issue/systems-approach-reduce-errors-surgery
August 10, 2016 - March 27, 2005
The culture of safety: results of an organization-wide survey in 15 California
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psnet.ahrq.gov/issue/inadvertent-administration-magnesium-sulfate-through-epidural-catheter-report-and-analysis
March 06, 2019 - June 10, 2015
A World Health Organization field trial assessing a proposed ICD-11 framework
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psnet.ahrq.gov/issue/improving-risk-management-lame-excuses-principled-practice
April 05, 2006 - May 3, 2023
A high-reliability organization framework for health care: a multiyear implementation
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psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
November 01, 2006 - But the hospital is also a very complex functional organization. … RW: How would you try to apply this thinking in a health care organization? … Interview
In Conversation with Timothy Vogus about High Reliability Organization
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psnet.ahrq.gov/perspective/conversation-kathleen-sanford-and-sue-schuelke-about-virtual-nursing
August 30, 2023 - We chose to invent our own, but if other organizations are looking for technology, there are many companies … Interview
In Conversation with Timothy Vogus about High Reliability Organization … February 26, 2025
Perspective
High Reliability Organization … Interview
In Conversation with Timothy Vogus about High Reliability Organization
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psnet.ahrq.gov/periodic-issue/periodic-issue-291
May 26, 2021 - Self-Reported Learning (SRL), a voluntary incident reporting system experience within a large health care organization … High reliability organizations encourage staff to self-report errors and hazards for comprehensive review