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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72788/psn-pdf
    February 24, 2021 - Harmed Patient Alliance. February 24, 2021 United Kingdom. https://psnet.ahrq.gov/issue/harmed-patient-alliance Patients and families that experience medical harm have unique support needs. This organization works to improve health system and clinician response to harmed patients. Their efforts aim to create a dee…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35197/psn-pdf
    December 09, 2008 - Analysis of errors enacted by surgical trainees during skills training courses. December 9, 2008 Tang B, Hanna GB, Cuschieri A. Analysis of errors enacted by surgical trainees during skills training courses. Surgery. 2005;138(1):14-20. https://psnet.ahrq.gov/issue/analysis-errors-enacted-surgical-trainees-during-s…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44436/psn-pdf
    October 30, 2017 - Overreaction. October 30, 2017 Shell ER. Overreaction. Scientific American. 2015;313(5):28-9. https://psnet.ahrq.gov/issue/overreaction Reporting on how test inaccuracies can lead to misdiagnosis of food allergies in children and the potential consequences, this magazine article describes a diagnostic tool to dete…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42344/psn-pdf
    September 24, 2016 - Strategies for preventing distractions and interruptions in the OR. September 24, 2016 Clark GJ. Strategies for preventing distractions and interruptions in the OR. AORN J. 2013;97(6):702-707. doi:10.1016/j.aorn.2013.01.018. https://psnet.ahrq.gov/issue/strategies-preventing-distractions-and-interruptions-or Dist…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60332/psn-pdf
    May 13, 2020 - Circle Up Training. May 13, 2020 Center for Medical Simulation. https://psnet.ahrq.gov/issue/circle-training Communication strategies are important for engaging staff in behaviors that support effective teamwork. This website highlights a process that involves briefings, supportive conversations, and debriefings a…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35951/psn-pdf
    June 14, 2011 - Errors in thyroid gland fine-needle aspiration. June 14, 2011 Raab SS, Vrbin CM, Grzybicki DM, et al. Errors in Thyroid Gland Fine-Needle Aspiration. Am J Clin Pathol. 2007;125(6). doi:10.1309/7rqe37k6439t4pb4. https://psnet.ahrq.gov/issue/errors-thyroid-gland-fine-needle-aspiration This AHRQ–funded study used roo…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34596/psn-pdf
    February 17, 2009 - Disclosure: what works now and what can work even better (part 3 of 3). February 17, 2009 Chicago, IL: American Society of Healthcare Risk Management;  https://psnet.ahrq.gov/issue/disclosure-what-works-now-and-what-can-work-even-better-part-3-3 A guide for communicating throughout the disclosure process, thi…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41995/psn-pdf
    September 24, 2016 - Momentary interruptions can derail the train of thought. September 24, 2016 Altmann EM, Trafton G, Hambrick DZ. Momentary interruptions can derail the train of thought. J Exp Psychol Gen. 2014;143(1):215-26. doi:10.1037/a0030986. https://psnet.ahrq.gov/issue/momentary-interruptions-can-derail-train-thought In this…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35917/psn-pdf
    July 23, 2010 - Audibility of patient clinical alarms to hospital nursing personnel. July 23, 2010 Sobieraj J, Ortega C, West I, et al. Audibility of patient clinical alarms to hospital nursing personnel. Mil Med. 2006;171(4):306-10. https://psnet.ahrq.gov/issue/audibility-patient-clinical-alarms-hospital-nursing-personnel The i…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42332/psn-pdf
    June 12, 2013 - Quality improvement through implementation of discharge order reconciliation. June 12, 2013 Lu Y, Clifford P, Bjorneby A, et al. Quality improvement through implementation of discharge order reconciliation. Am J Health Syst Pharm. 2013;70(9):815-20. doi:10.2146/ajhp120050. https://psnet.ahrq.gov/issue/quality-impr…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38285/psn-pdf
    December 10, 2008 - AHRQ Risk-informed Intervention Development and Implementation of Safe Practices in Ambulatory Care. December 10, 2008 Rockville, MD: Agency for Healthcare Research and Quality; October 2008. https://psnet.ahrq.gov/issue/ahrq-risk-informed-intervention-development-and-implementation-safe- practices-ambulatory-care…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38898/psn-pdf
    August 26, 2009 - Emergency response in outpatient oncology care: improving patient safety. August 26, 2009 Schiavone R. Emergency response in outpatient oncology care: improving patient safety. Clin J Oncol Nurs. 2009;13(4):440-2. doi:10.1188/09.CJON.440-442. https://psnet.ahrq.gov/issue/emergency-response-outpatient-oncology-care…

  13. Western Institute for Biomedical Research | Digital Healthcare Research

    digital.ahrq.gov/organization/western-institute-biomedical-research
    January 01, 2023 - Western Institute for Biomedical Research Veterans Administration (VA) Integrated Medication Manager - 2011 Principal Investigator Nebeker, Jonathan Project Name Veterans Administration (VA) Integrated Medication Manager Veterans Administr…

  14. Exhibit 5.15. Outcomes by Category | Agency for Healthcare Research and Quality

    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit5-15.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 5.15. Outcomes by Category Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Healthcare Case 2. Central Hospital…

  15. Exhibit 4.15. Project Team Composition—Electronic Prescribing | Agency for Healthcare Research and Quality

    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit4-15.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 4.15. Project Team Composition—Electronic Prescribing Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Healthcare…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47556/psn-pdf
    November 28, 2018 - Improving Diagnosis. November 28, 2018 Deutsch E, ed. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):1-70. https://psnet.ahrq.gov/issue/improving-diagnosis This special issue raises awareness of challenges to reducing diagnostic error. Articles discuss insights from experts about how to improve diagnosis, t…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41711/psn-pdf
    September 26, 2012 - Beyond FMEA: the structured what-if technique (SWIFT). September 26, 2012 Card AJ, Ward JR, Clarkson PJ. Beyond FMEA: The structured what-if technique (SWIFT). J Healthc Risk Manag. 2012;31(4):23-29. doi:10.1002/jhrm.20101. https://psnet.ahrq.gov/issue/swift-new-tool-identifying-prospective-hazards This commentary…

  18. 2013 Child Core Set Measurement Retirement | Agency for Healthcare Research and Quality

    www.ahrq.gov/policymakers/chipra/measure_retirement/supplemental-materials/index.html
    August 01, 2014 - 2013 Child Core Set Measurement Retirement Supplemental Documents The following supplemental documents for Systematic Evidence-Based Quality Measurement Life-Cycle Approach to Measure Retirement in CHIPRA are available: Supplemental Document No. 1: Information Types and Sources Relevant to the 2013 SNA…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50633/psn-pdf
    November 06, 2019 - Findings of Two Inaugural Leapfrog Surveys 2019. November 6, 2019 Washington DC: Leapfrog Group; 2019. https://psnet.ahrq.gov/issue/findings-two-inaugural-leapfrog-surveys-2019 Ambulatory surgery centers (ASC) are established venues for surgical care despite engagement in assessment to ensure their safety. This re…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43800/psn-pdf
    August 02, 2016 - Patient Safety Culture: Theory, Methods and Application. August 2, 2016 Waterson P, ed. London, UK: Ashgate; 2014. ISBN: 9781409448143. https://psnet.ahrq.gov/issue/patient-safety-culture-theory-methods-and-application This publication covers patient safety culture including its background in high-risk industries, …
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