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8001. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60937/psn-pdf
      September 23, 2020 - The practice of medicine: understanding diagnostic error. September 23, 2020 Cantey C. The practice of medicine: understanding diagnostic error. J Nurs Pract. 2020;16(8):582-585. doi:10.1016/j.nurpra.2020.05.014. https://psnet.ahrq.gov/issue/practice-medicine-understanding-diagnostic-error This article discusses c…

8002. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36816/psn-pdf
      August 26, 2011 - Embedding quality improvement and patient safety - the UCLA value analysis experience. August 26, 2011 Gambone JC, Broder MS. Embedding quality improvement and patient safety: the UCLA value analysis experience. Best Pract Res Clin Obstet Gynaecol. 2007;21(4):581-92. https://psnet.ahrq.gov/issue/embedding-quality-…

8003. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37713/psn-pdf
      June 07, 2008 - Giving back the pen: disclosure, apology and early compensation discussions after harm in the healthcare setting. June 7, 2008 Pelletier E, Robson. Healthc Q. 2008;11(3 Spec No):85-90. https://psnet.ahrq.gov/issue/giving-back-pen-disclosure-apology-and-early-compensation-discussions-after- harm-healthcare This c…

8004. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46442/psn-pdf
      October 04, 2017 - Handoff Communication. October 4, 2017 APSF Newsletter. October 2017;32:29-56. https://psnet.ahrq.gov/issue/handoff-communication Handoff processes are known to carry risks of communication errors. This special issue focuses on transfers involving anesthesia care. Articles review different types of handoffs, chara…

8005. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44622/psn-pdf
      November 04, 2015 - Medical errors in dentistry. November 4, 2015 Nagelberg R. RDH. September 2015;35:79-85. https://psnet.ahrq.gov/issue/medical-errors-dentistry Little is currently known about the types of safety issues in dentistry. This magazine article discusses common adverse events in dental care and recommends strategies to i…

8006. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46998/psn-pdf
      August 01, 2019 - 10 Facts on Patient Safety. June 27, 2018 Patient Safety and Risk Management Service Delivery and Safety. Geneva, Switzerland; World Health Organization: August 2019. https://psnet.ahrq.gov/issue/10-facts-patient-safety This publication highlights statistics that illustrate the global impact of patient harm. The i…

8007. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50455/psn-pdf
      October 09, 2019 - Advancing a More Health-Literate Approach to Patient Safety October 9, 2019 Sanders LM. Advancing a More Health-Literate Approach to Patient Safety. J Pediatr. 2019;214:10-11. doi:10.1016/j.jpeds.2019.07.003. https://psnet.ahrq.gov/issue/advancing-more-health-literate-approach-patient-safety Health literacy is th…

8008. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35504/psn-pdf
      February 22, 2010 - Dispensing error rate in a highly automated mail-service pharmacy practice. February 22, 2010 Teagarden R, Nagle B, Aubert RE, et al. Dispensing error rate in a highly automated mail-service pharmacy practice. Pharmacotherapy. 2005;25(11):1629-35. https://psnet.ahrq.gov/issue/dispensing-error-rate-highly-automated…

8009. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36301/psn-pdf
      October 26, 2010 - The culture of a trauma team in relation to human factors. October 26, 2010 Cole E, Crichton N. The culture of a trauma team in relation to human factors. J Clin Nurs. 2006;15(10). doi:10.1111/j.1365-2702.2006.01566.x. https://psnet.ahrq.gov/issue/culture-trauma-team-relation-human-factors The investigators observ…

8010. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46824/psn-pdf
      June 26, 2018 - Management reasoning: beyond the diagnosis. June 26, 2018 Cook DA, Sherbino J, Durning SJ. Management Reasoning: Beyond the Diagnosis. JAMA. 2018;319(22):2267-2268. doi:10.1001/jama.2018.4385. https://psnet.ahrq.gov/issue/management-reasoning-beyond-diagnosis This commentary reviews five differences between diagno…

8011. Exhibit 6.12. Outcomes by Category | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit6-12.html
      November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 6.12. 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…

8012. Exhibit 2.12. Outcomes by Category | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit2-12.html
      November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 2.12. 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…

8013. Exhibit 1.16. Outcomes by Category | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit1-16.html
      November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 1.16. 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…

8014. Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/worksheet.html
      July 01, 2023 - Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership AHRQ Safety Program for Perinatal Care Purpose: To enhance communication and shared problem solving between clinical staff and senior executives with respect to patient safety issues on the labor and delivery unit. …

8015. Podcast: Building Your Business Case for Your Quality Improvement Project | Agency for Healthcare Research and Quality
      www.ahrq.gov/evidencenow/tools/podcast-business-case.html
      February 01, 2025 - Podcast: Building Your Business Case for Your Quality Improvement Project Resource: Building Your Business Case for Your Quality Improvement Project: Why It's Important (mp3, 32:16 minutes) In this podcast, Jim Campbell, MD, explores practical tools for implementing quality improvement activities and creati…

8016. Exhibit 3.17. Outcomes by Category | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit3-17.html
      November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 3.17. 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…

8017. Exhibit 4.16. Outcomes by Category | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit4-16.html
      November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 4.16. 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…

8018. Disposition of Comments Report for Relationship Between Use of Quality Measures and Improved Outcomes in Serious Mental Illness (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/mental-illness-outcomes_disposition-comments.pdf
      January 15, 2015 - Disposition of Comments Report for Relationship Between Use of Quality Measures and Improved Outcomes in Serious Mental Illness Research Review Title: Relationship Between Use of Quality Measures and Improved Outcomes in Serious Mental Illness Draft review available for public comment from July10, 2014 to A…

8019. A Prospective Comparison of Evidence Synthesis Search Strategies Developed With and Without Text-Mining Tools (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/methods-results-search-strategies-developed-with-without-text-mining-tools.pdf
      March 01, 2021 - A Prospective Comparison of Evidence Synthesis Search Strategies Developed With and Without Text-Mining Tools Methods Research Report A Prospective Comparison of Evidence Synthesis Search Strategies Developed With and Without Text- Mining Tools Methods Rese…

8020. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49853/psn-pdf
      February 01, 2019 - Adverse Event During Intrahospital Transport February 1, 2019 Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport The Case A 4-year-old boy underwent surgery under general anesthesia for correction o…