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  1. Using participatory design to engage physicians in the development of a provider-level performance dashboard and feedback system. | PSNet

    psnet.ahrq.gov/issue/using-participatory-design-engage-physicians-development-provider-level-performance-dashboard
    October 28, 2020 - Study Using participatory design to engage physicians in the development of a provider-level performance dashboard and feedback system. Citation Text: Patel S, Pierce L, Jones M, et al. Using participatory design to engage physicians in the development of a provider-level performance da…

  2. Organisational culture: variation across hospitals and connection to patient safety climate. | PSNet

    psnet.ahrq.gov/issue/organisational-culture-variation-across-hospitals-and-connection-patient-safety-climate
    March 17, 2010 - Study Organisational culture: variation across hospitals and connection to patient safety climate. Citation Text: Speroff T, Nwosu S, Greevy R, et al. Organisational culture: variation across hospitals and connection to patient safety climate. Qual Saf Health Care. 2010;19(6):592-6. do…

  3. An assessment of the impact of just culture on quality and safety in US hospitals. | PSNet

    psnet.ahrq.gov/issue/assessment-impact-just-culture-quality-and-safety-us-hospitals
    April 13, 2017 - Study Emerging Classic An assessment of the impact of just culture on quality and safety in US hospitals. Citation Text: Edwards MT. An Assessment of the Impact of Just Culture on Quality and Safety in US Hospitals. Am J Med Qual. 2018;33(5):502-508. doi:10.1177…

  4. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. | PSNet

    psnet.ahrq.gov/issue/preventable-adverse-drug-events-hospitalized-patients-comparative-study-intensive-care-and
    March 31, 2021 - Study Classic Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Citation Text: Cullen DJ, Sweitzer BJ, Bates DW, et al. Preventable adverse drug events in hospitalized patients. Crit Care Me…

  5. Creating a framework to integrate residency program and medical center approaches to quality improvement and patient safety training | PSNet

    psnet.ahrq.gov/issue/creating-framework-integrate-residency-program-and-medical-center-approaches-quality
    November 11, 2020 - Commentary Creating a framework to integrate residency program and medical center approaches to quality improvement and patient safety training Citation Text: Chen A, Wolpaw BJ, Vande Vusse LK, et al. Creating a framework to integrate residency program and medical center approaches to qu…

  6. The enabling, enacting, and elaborating factors of safety culture associated with patient safety: a multilevel analysis. | PSNet

    psnet.ahrq.gov/issue/enabling-enacting-and-elaborating-factors-safety-culture-associated-patient-safety-multilevel
    September 21, 2022 - Study The enabling, enacting, and elaborating factors of safety culture associated with patient safety: a multilevel analysis. Citation Text: Lee SE, Dahinten VS. The enabling, enacting, and elaborating factors of safety culture associated with patient safety: a multilevel analysis. J Nu…

  7. Bracing for the storm: one health care system's planning for the COVID-19 surge. | PSNet

    psnet.ahrq.gov/issue/bracing-storm-one-health-care-systems-planning-covid-19-surge
    July 22, 2020 - Commentary Bracing for the storm: one health care system's planning for the COVID-19 surge. Citation Text: Kim CS, Meo N, Little D, et al. Bracing for the storm: one health care system's planning for the COVID-19 surge. Jt Comm J Qual Patient Saf. 2021;47(1):60-68. doi:10.1016/j.jcjq.202…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846922/psn-pdf
    March 29, 2023 - Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes March 29, 2023 https://psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions- and-improve-health Summary With increasing recognition that health is linked to the condit…

  9. Check the Bags | PSNet

    psnet.ahrq.gov/web-mm/check-bags
    January 03, 2017 - Check the Bags Citation Text: Caldwell M, Dracup KA. Check the Bags. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33821/psn-pdf
    December 01, 2016 - Errors and Near Misses: What Health Care Could Learn From Aviation December 1, 2016 Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation Perspective Some of the most urg…

  11. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
    January 01, 2020 - Spotlight Spotlight Inpatient Stroke Management in a Patient with Type 1 Diabetes and Home Insulin Pump Source and Credits • This presentation is based on the October 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Berit B…

  12. Hemolysis Holdup | PSNet

    psnet.ahrq.gov/web-mm/hemolysis-holdup
    July 03, 2016 - Hemolysis Holdup Citation Text: Lehman CM. Hemolysis Holdup. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  13. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience | PSNet

    psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
    December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005  View more articles from the same authors. Citation Text: Conway JB, Weingart SN. Organizational Change…

  14. The Hidden Harms of Hand Sanitizer | PSNet

    psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer
    March 04, 2020 - The Hidden Harms of Hand Sanitizer Citation Text: Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …

  15. Radiation Safety | PSNet

    psnet.ahrq.gov/primer/radiation-safety
    September 15, 2024 - Radiation Safety Citation Text: Radiation Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Downl…

  16. Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture. | PSNet

    psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
    November 25, 2020 - Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture. Citation Text: Barnes DK, Randhawa SDS, Fitzpatrick EP. Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US De…

  17. Diagnostic Errors | PSNet

    psnet.ahrq.gov/perspective/diagnostic-errors
    December 01, 2013 - Annual Perspective Diagnostic Errors Urmimala Sarkar, MD; Kaveh Shojania, MD | January 1, 2014  Also Read a Conversation View more articles from the same authors. Citation Text: Sarkar U, Shojania KG. Diagnostic Errors. PSNet [internet]. Rockville (MD): Ag…

  18. How will we know patients are safer? An organization-wide approach to measuring and improving safety. | PSNet

    psnet.ahrq.gov/issue/how-will-we-know-patients-are-safer-organization-wide-approach-measuring-and-improving-safety
    May 20, 2009 - Study How will we know patients are safer? An organization-wide approach to measuring and improving safety. Citation Text: Pronovost P, Holzmueller CG, Needham DM, et al. How will we know patients are safer? An organization-wide approach to measuring and improving safety. Crit Care Med…

  19. Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps. | PSNet

    psnet.ahrq.gov/issue/why-test-results-are-still-getting-lost-follow-qualitative-study-implementation-gaps
    June 22, 2022 - Study Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps. Citation Text: Zimolzak AJ, Shahid U, Giardina TD, et al. Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps. J Gen Intern Med. 2022;3…

  20. Potentially inappropriate medication use is associated with increased risk of incident disability in healthy older adults. | PSNet

    psnet.ahrq.gov/issue/potentially-inappropriate-medication-use-associated-increased-risk-incident-disability
    October 19, 2022 - Study Potentially inappropriate medication use is associated with increased risk of incident disability in healthy older adults. Citation Text: Lockery JE, Collyer TA, Woods RL, et al. Potentially inappropriate medication use is associated with increased risk of incident disability in he…
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