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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34715/psn-pdf
    February 18, 2011 - Continuous improvement as an ideal in health care. February 18, 2011 Berwick D. Continuous improvement as an ideal in health care. New Engl J Med. 1989;320(1):53-56. https://psnet.ahrq.gov/issue/continuous-improvement-ideal-health-care Two approaches to improving quality in health care are illustrated in this artic…

  2. Hancock County Health Services | Digital Healthcare Research

    digital.ahrq.gov/organization/hancock-county-health-services
    January 01, 2023 - Hancock County Health Services Electronic Health Record Implementation for Continuum of Care in Rural Iowa - 2008 Principal Investigator O'Brien, John Project Name Electronic Health Record Implementation for Continuum of Care in Rural Iowa …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50554/psn-pdf
    October 16, 2019 - Adverse events in the operating room: definitions, prevalence, and characteristics. A systematic review. October 16, 2019 Jung JJ, Elfassy J, Jüni P, et al. Adverse Events in the Operating Room: Definitions, Prevalence, and Characteristics. A Systematic Review. World J Surg. 2019;43(10):2379-2392. doi:10.1007/s0026…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866160/psn-pdf
    June 19, 2024 - Checking all the boxes: a checklist for when and how to use checklists effectively. June 19, 2024 Alfred M, Barg-Walkow LH, Keebler JR, et al. Checking all the boxes: a checklist for when and how to use checklists effectively. BMJ Qual Saf. 2024;33(10):673-681. doi:10.1136/bmjqs-2023-016934. https://psnet.ahrq.gov…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74231/psn-pdf
    January 12, 2022 - Quality and safety in hospital pediatrics during COVID-19: a national qualitative study. January 12, 2022 De Angulo NR, Penwill N, Pathak PR, et al. Quality and safety in hospital pediatrics during COVID-19: a national qualitative study. Hosp Pediatr. 2022;12(1):e2021006115. doi:10.1542/hpeds.2021-006115. https://…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854993/psn-pdf
    November 01, 2023 - Building cultures of high reliability: lessons from the high reliability organization paradigm. November 1, 2023 Sutcliffe KM. Building cultures of high reliability: lessons from the high reliability organization paradigm. Anesthesiol Clin. 2023;41(4):707-717. doi:10.1016/j.anclin.2023.03.012. https://psnet.ahrq.g…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74053/psn-pdf
    November 10, 2021 - Prevention of failure to rescue in obstetric patients: a realist review. November 10, 2021 Bernstein SL, Kelechi TJ, Catchpole K, et al. Prevention of failure to rescue in obstetric patients: a realist review. Worldviews Evid Based Nurs. 2021;18(6):352-360. doi:10.1111/wvn.12531. https://psnet.ahrq.gov/issue/preve…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48045/psn-pdf
    June 05, 2019 - Obstetric practice guidelines: labor's love lost? June 5, 2019 Cohen WR, Friedman EA. Obstetric practice guidelines: labor's love lost? J Matern Fetal Neonatal Med. 2019;32(9):1567-1570. doi:10.1080/14767058.2017.1406474. https://psnet.ahrq.gov/issue/obstetric-practice-guidelines-labors-love-lost Guidelines play a…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866815/psn-pdf
    September 25, 2024 - Why a sociotechnical framework is necessary to address diagnostic error. September 25, 2024 Ladell MM, Yale S, Bordini BJ, et al. Why a sociotechnical framework is necessary to address diagnostic error. BMJ Qual Saf. 2024;33(12):823-828. doi:10.1136/bmjqs-2024-017231. https://psnet.ahrq.gov/issue/why-sociotechnica…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863757/psn-pdf
    March 06, 2024 - Debriefing to improve interprofessional teamwork in the operating room: a systematic review. March 6, 2024 Skegg E, McElroy C, Mudgway M, et al. Debriefing to improve interprofessional teamwork in the operating room: a systematic review. J Nurs Scholarsh. 2023;55(6):1179-1188. doi:10.1111/jnu.12924. https://psnet.…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46691/psn-pdf
    December 06, 2017 - Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns. December 6, 2017 Washington, DC: United States Government Accountability Office; November 2017. Publication GAO-18- 63. https://psnet.ahrq.gov/issue/improved-policies-and-oversight-needed-reviewing-and-rep…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60227/psn-pdf
    April 15, 2020 - The next step in learning from sentinel events in healthcare. April 15, 2020 Bos K, Dongelmans DA, Greuters S, et al. The next step in learning from sentinel events in healthcare. BMJ Open Qual. 2020;9(1):e000739. doi:10.1136/bmjoq-2019-000739. https://psnet.ahrq.gov/issue/next-step-learning-sentinel-events-health…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45332/psn-pdf
    August 27, 2018 - Guideline implementation: prevention of retained surgical items. August 27, 2018 Fencl JL. Guideline Implementation: Prevention of Retained Surgical Items. AORN J. 2016;104(1):37-48. doi:10.1016/j.aorn.2016.05.005. https://psnet.ahrq.gov/issue/guideline-implementation-prevention-retained-surgical-items Although i…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35017/psn-pdf
    August 24, 2017 - The Field Guide to Human Error Investigations, Third Edition. August 24, 2017 Dekker S. Boca Baton, FL: CRC Press; 2017. https://psnet.ahrq.gov/issue/field-guide-human-error-investigations-third-edition This revised and reorganized book provides a primer on how human error causes mishaps and often illustrates dee…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850911/psn-pdf
    June 21, 2023 - International perspectives on modifications to the surgical safety checklist. June 21, 2023 Turley N, Elam M, Brindle ME. International perspectives on modifications to the surgical safety checklist. JAMA Netw Open. 2023;6(6):e2317183. doi:10.1001/jamanetworkopen.2023.17183. https://psnet.ahrq.gov/issue/internatio…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44171/psn-pdf
    May 27, 2015 - Aiming higher to enhance professionalism: beyond accreditation and certification. May 27, 2015 Chassin MR, Baker DW. Aiming higher to enhance professionalism: beyond accreditation and certification. JAMA. 2015;313(18):1795-6. doi:10.1001/jama.2015.3818. https://psnet.ahrq.gov/issue/aiming-higher-enhance-profession…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43876/psn-pdf
    September 09, 2015 - Improving medication administration safety in a community hospital setting using Lean methodology. September 9, 2015 Critchley S. Improving medication administration safety in a community hospital setting using Lean methodology. J Nurs Care Qual. 2015;30(4):345-351. doi:10.1097/NCQ.0000000000000112. https://psnet.…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837590/psn-pdf
    June 29, 2022 - Diagnostic challenges in primary care: identifying and avoiding cognitive bias. June 29, 2022 Rosen PD, Klenzak S, Baptista S. Diagnostic challenges in primary care: identifying and avoiding cognitive bias. J Fam Pract. 2022;71(3):124-132. doi:10.12788/jfp.0380. https://psnet.ahrq.gov/issue/diagnostic-challenges-p…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37255/psn-pdf
    December 19, 2011 - Communicating in the "gray zone": perceptions about emergency physician-hospitalist handoffs and patient safety. December 19, 2011 Apker J, Mallak LA, Gibson SC. Communicating in the "gray zone": perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007;14(10):884-94. htt…

  20. Do It Yourself Run Chart for Primary Care Practices | Agency for Healthcare Research and Quality

    www.ahrq.gov/evidencenow/tools/diy-run-chart.html
    July 01, 2022 - Do It Yourself Run Chart for Primary Care Practices Resource: Do It Yourself Run Chart  (XLSX, 86 KB) Primary care practices can use this Excel spreadsheet to create run charts to track their progress in quality improvement. It includes instructions, an example of a diabetes measure, and a programmed blank s…
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