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  1. Iatrogenic harm caused by diagnostic errors in fibrodysplasia ossificans progressiva. | PSNet

    psnet.ahrq.gov/issue/iatrogenic-harm-caused-diagnostic-errors-fibrodysplasia-ossificans-progressiva
    November 16, 2022 - Study Iatrogenic harm caused by diagnostic errors in fibrodysplasia ossificans progressiva. Citation Text: Kitterman JA, Kantanie S, Rocke DM, et al. Iatrogenic harm caused by diagnostic errors in fibrodysplasia ossificans progressiva. Pediatrics. 2005;116(5):e654-61. Copy Citation …

  2. Using simulation to teach nursing students and licensed clinicians obstetric emergencies. | PSNet

    psnet.ahrq.gov/issue/using-simulation-teach-nursing-students-and-licensed-clinicians-obstetric-emergencies
    November 11, 2020 - Commentary Using simulation to teach nursing students and licensed clinicians obstetric emergencies. Citation Text: Alderman JT. Using simulation to teach nursing students and licensed clinicians obstetric emergencies. MCN Am J Matern Child Nurs. 2012;37(6):394-400. doi:10.1097/NMC.0b0…

  3. Medical overuse as a physician cognitive error: looking under the hood. | PSNet

    psnet.ahrq.gov/issue/medical-overuse-physician-cognitive-error-looking-under-hood
    September 25, 2019 - Commentary Medical overuse as a physician cognitive error: looking under the hood. Citation Text: Korenstein D. Medical overuse as a physician cognitive error: looking under the hood. JAMA Intern Med. 2019;179(1):26-27. doi:10.1001/jamainternmed.2018.5136. Copy Citation Format: …

  4. The sterile cockpit: an effective approach to reducing medication errors? | PSNet

    psnet.ahrq.gov/issue/sterile-cockpit-effective-approach-reducing-medication-errors
    April 24, 2018 - Commentary The sterile cockpit: an effective approach to reducing medication errors? Citation Text: Federwisch M, Ramos H, Adams S' C. The sterile cockpit: an effective approach to reducing medication errors? Am J Nurs. 2014;114(2):47-55. doi:10.1097/01.NAJ.0000443777.80999.5c. Copy Ci…

  5. A relational leadership perspective on unit-level safety climate. | PSNet

    psnet.ahrq.gov/issue/relational-leadership-perspective-unit-level-safety-climate
    April 24, 2018 - Study A relational leadership perspective on unit-level safety climate. Citation Text: Thompson DN, Hoffman LA, Sereika SM, et al. A relational leadership perspective on unit-level safety climate. J Nurs Adm. 2011;41(11):479-87. doi:10.1097/NNA.0b013e3182346e31. Copy Citation For…

  6. The aging surgeon. | PSNet

    psnet.ahrq.gov/issue/aging-surgeon
    February 22, 2019 - Review The aging surgeon. Citation Text: Katlic MR, Coleman JA. The Aging Surgeon. Adv Surg. 2016;50(1):93-103. doi:10.1016/j.yasu.2016.03.008. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download…

  7. How one medical checkup can snowball into a ‘cascade’ of tests, causing more harm than good. | PSNet

    psnet.ahrq.gov/issue/how-one-medical-checkup-can-snowball-cascade-tests-causing-more-harm-good
    February 03, 2021 - Newspaper/Magazine Article How one medical checkup can snowball into a ‘cascade’ of tests, causing more harm than good. Citation Text: How one medical checkup can snowball into a ‘cascade’ of tests, causing more harm than good. Ganguli I. Washington Post. January 5, 2020. Copy Citati…

  8. Work system design for patient safety: the SEIPS model. | PSNet

    psnet.ahrq.gov/issue/work-system-design-patient-safety-seips-model
    December 18, 2013 - Commentary Work system design for patient safety: the SEIPS model. Citation Text: Carayon P, Schoofs Hundt A, Karsh B-T, et al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care. 2006;15(suppl 1):i50-i58. doi:10.1136/qshc.2005.015842. Copy Citation Form…

  9. Engineering a foundation for partnership to improve medication safety during care transitions. | PSNet

    psnet.ahrq.gov/issue/engineering-foundation-partnership-improve-medication-safety-during-care-transitions
    July 20, 2022 - Commentary Engineering a foundation for partnership to improve medication safety during care transitions. Citation Text: Xiao Y, Abebe E, Gurses AP. Engineering a Foundation for Partnership to Improve Medication Safety during Care Transitions. J Patient Saf Risk Manag. 2019;24(1):30-36. …

  10. Simulation, mastery learning and healthcare. | PSNet

    psnet.ahrq.gov/issue/simulation-mastery-learning-and-healthcare
    November 09, 2011 - Commentary Simulation, mastery learning and healthcare. Citation Text: Dunn W, Dong Y, Zendejas B, et al. Simulation, Mastery Learning and Healthcare. Am J Med Sci. 2017;353(2):158-165. doi:10.1016/j.amjms.2016.12.012. Copy Citation Format: DOI Google Scholar PubMed BibTeX …

  11. Second-victim phenomenon. | PSNet

    psnet.ahrq.gov/issue/second-victim-phenomenon
    July 10, 2024 - Review Second-victim phenomenon. Citation Text: New L, Lambeth T. Second-victim phenomenon. Nurs Clin North Am. 2024;59(1):141-152. doi:10.1016/j.cnur.2023.11.011. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  12. Development and validation of a tool to improve paediatric referral/consultation communication. | PSNet

    psnet.ahrq.gov/issue/development-and-validation-tool-improve-paediatric-referralconsultation-communication
    May 25, 2011 - Study Development and validation of a tool to improve paediatric referral/consultation communication. Citation Text: Stille CJ, Mazor KM, Meterko V, et al. Development and validation of a tool to improve paediatric referral/consultation communication. BMJ Qual Saf. 2011;20(8):692-7. do…

  13. Case study: getting boards on board at Allen Memorial Hospital, Iowa Health System. | PSNet

    psnet.ahrq.gov/issue/case-study-getting-boards-board-allen-memorial-hospital-iowa-health-system
    August 04, 2021 - Commentary Case study: getting boards on board at Allen Memorial Hospital, Iowa Health System. Citation Text: Slessor SR, Crandall JB, Nielsen GA. Case study: getting boards on board at Allen Memorial Hospital, Iowa Health System. Jt Comm J Qual Patient Saf. 2008;34(4):221-227. Copy …

  14. INSTRUCTIONS: Project Charter (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/d2-projectcharter.pdf
    December 23, 2009 - INSTRUCTIONS: Project Charter AHRQ Quality Indicators Toolkit INSTRUCTIONS Project Charter What is this tool? The purpose of the project charter is to describe the performance improvement rationale, goals, barriers, and anticipated resources to which the team will commit. Who are the target audiences? St…

  15. Malpractice liability and health care quality: a review | PSNet

    psnet.ahrq.gov/issue/malpractice-liability-and-health-care-quality-review
    April 13, 2011 - Review Emerging Classic Malpractice liability and health care quality: a review Citation Text: Mello MM, Frakes MD, Blumenkranz E, et al. Malpractice liability and health care quality: A review . JAMA. 2020;323(4):352-366. doi:10.1001/jama.2019.21411. Copy Cit…

  16. Predictors of warfarin-associated adverse events in hospitalized patients: opportunities to prevent patient harm. | PSNet

    psnet.ahrq.gov/issue/predictors-warfarin-associated-adverse-events-hospitalized-patients-opportunities-prevent
    August 03, 2016 - Review Predictors of warfarin-associated adverse events in hospitalized patients: opportunities to prevent patient harm. Citation Text: Metersky M, Eldridge N, Wang Y, et al. Predictors of warfarin-associated adverse events in hospitalized patients: Opportunities to prevent patient harm.…

  17. 'Between the flags': implementing a rapid response system at scale. | PSNet

    psnet.ahrq.gov/issue/between-flags-implementing-rapid-response-system-scale
    June 08, 2011 - Commentary 'Between the flags': implementing a rapid response system at scale. Citation Text: Hughes C, Pain C, Braithwaite J, et al. 'Between the flags': implementing a rapid response system at scale. BMJ Qual Saf. 2014;23(9):714-7. doi:10.1136/bmjqs-2014-002845. Copy Citation For…

  18. Elective surgical patients' narratives of hospitalization: the co-construction of safety. | PSNet

    psnet.ahrq.gov/issue/elective-surgical-patients-narratives-hospitalization-co-construction-safety
    May 29, 2012 - Study Elective surgical patients' narratives of hospitalization: the co-construction of safety. Citation Text: DOHERTY CAROLE, Saunders MNK. Elective surgical patients' narratives of hospitalization: the co-construction of safety. Soc Sci Med. 2013;98:29-36. doi:10.1016/j.socscimed.2013…

  19. Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events. | PSNet

    psnet.ahrq.gov/issue/indian-health-service-actions-needed-improve-use-data-adverse-events
    September 07, 2016 - Book/Report Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events. Citation Text: Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events. Washington, DC: United States Government Accounting Office; July 10, 2023.  Publication GAO-23-1…

  20. Bringing the equity lens to patient safety event reporting. | PSNet

    psnet.ahrq.gov/issue/bringing-equity-lens-patient-safety-event-reporting
    September 21, 2009 - Commentary Bringing the equity lens to patient safety event reporting. Citation Text: Gandhi TK, Schulson LB, Thomas AD. Bringing the equity lens to patient safety event reporting. Jt Comm J Qual Patient Saf. 2024;50(1):87-89. doi:10.1016/j.jcjq.2023.09.003. Copy Citation Format: …
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