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9841. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840147/psn-pdf
      November 16, 2022 - Electronic diagnostic support in emergency physician triage: qualitative study with thematic analysis of interviews. November 16, 2022 Sibbald M, Abdulla B, Keuhl A, et al. Electronic diagnostic support in emergency physician triage: qualitative study with thematic analysis of interviews. JMIR Hum Factors. 2022;9(…

9842. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47198/psn-pdf
      August 22, 2018 - Health IT Safe Practices for Closing the Loop. August 22, 2018 Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI; August 2018. https://psnet.ahrq.gov/issue/health-it-safe-practices-closing-loop Inadequate follow-up of test results can contribute to missed and delayed diagnoses. Developing optimal…

9843. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36902/psn-pdf
      June 09, 2010 - Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. June 9, 2010 Catchpole K, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr …

9844. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60540/psn-pdf
      November 01, 2016 - Quality improvement initiatives lead to reduction in nulliparous term singleton vertex cesarean delivery rate. November 1, 2016 Vadnais MA, Hacker MR, Shah NT, et al. Quality improvement initiatives lead to reduction in nulliparous term singleton vertex cesarean delivery rate. Jt Comm J Qual Patient Saf. 2016;43(2)…

9845. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/862988/psn-pdf
      February 21, 2024 - Identifying and classifying diagnostic errors in acute care across hospitals: early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study. February 21, 2024 Dalal AK, Schnipper JL, Raffel K, et al. Identifying and classifying diagnostic errors in acute care across hospitals: early less…

9846. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36386/psn-pdf
      July 14, 2010 - Learning from different lenses: reports of medical errors in primary care by clinicians, staff, and patients: a project of the American Academy of Family Physicians National Research Network. July 14, 2010 Phillips RL, Dovey SM, Graham D, et al. Learning From Different Lenses: Reports of Medical Errors in Primary…

9847. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853959/psn-pdf
      September 27, 2023 - Scaling up a diagnostic pause at the ICU-to-ward transition: an exploration of barriers and facilitators to implementation of the ICU-PAUSE handoff tool. September 27, 2023 Cornell EG, Harris E, McCune E, et al. Scaling up a diagnostic pause at the ICU-to-ward transition: an exploration of barriers and facilitator…

9848. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836984/psn-pdf
      April 27, 2022 - A 6-year thematic review of reported incidents associated with cardiopulmonary resuscitation calls in a United Kingdom hospital. April 27, 2022 Beed M, Hussain S, Woodier N, et al. A 6-year thematic review of reported incidents associated with cardiopulmonary resuscitation calls in a United Kingdom hospital. J Pat…

9849. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/764398/psn-pdf
      March 02, 2022 - What do we really know about crew resource management in healthcare?: An umbrella review on crew resource management and its effectiveness. March 2, 2022 Buljac-Samardzic M, Dekker-van Doorn CM, Maynard MT. What do we really know about crew resource management in healthcare?: An umbrella review on crew resource ma…

9850. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41211/psn-pdf
      January 03, 2017 - He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices. January 3, 2017 Phipps E, Turkel M, Mackenzie ER, et al. He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices. Jt Comm J Qual P…

9851. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836824/psn-pdf
      March 30, 2022 - Collaborative case review: a systems-based approach to patient safety event investigation and analysis. March 30, 2022 Lacson R, Khorasani R, Fiumara K, et al. Collaborative case review: a systems-based approach to patient safety event investigation and analysis. J Patient Saf. 2022;18(2):e522-e527. doi:10.1097/pt…

9852. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72855/psn-pdf
      March 17, 2021 - We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptations. March 17, 2021 Panda N, Etheridge JC, Singh T, et al. The WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptation…

9853. ESRD Toolkit Modules | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/esrd/resource/tool-module.html
      January 01, 2015 - ESRD Toolkit Modules Modules contain PowerPoint slides, facilitator notes, video vignettes, and tools. Each module includes teaching tools and resources to support change at the unit level, presented through facilitator notes that take you step by step through the slides, tools, and videos. Creating a Culture…

9854. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50447/psn-pdf
      October 09, 2019 - Patient safety incidents in advance care planning for serious illness: a mixed-methods analysis October 9, 2019 Dinnen T, Williams H, Yardley S, et al. Patient safety incidents in advance care planning for serious illness: a mixed-methods analysis. BMJ Support Palliat Care. 2019. doi:10.1136/bmjspcare-2019-001824. …

9855. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/849340/psn-pdf
      May 24, 2023 - Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment for Persons with Mental Health Disabilities. May 24, 2023 Massachusetts Protection and Advocacy. Boston, MA:  Disability Law Center; May 8, 2023. https://psnet.ahrq.gov/issue/death-inside-lemuel-shattuck-hospital-case-study-medical-treat…

9856. Evaluating the Cost-Effectiveness of a Quality Reporting Project | Agency for Healthcare Research and Quality
      www.ahrq.gov/talkingquality/assess/what-you-evaluate/cost-effectiveness.html
      November 01, 2018 - Evaluating the Cost-Effectiveness of a Quality Reporting Project Report sponsors often want to know whether the reporting project was a good use of limited resources. While it is often difficult and inappropriate to try to justify the expense of an entire quality reporting project based on quantifiable results,…

9857. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46285/psn-pdf
      August 02, 2017 - A hospital is not just a factory, but a complex adaptive system—implications for perioperative care. August 2, 2017 Mahajan A, Islam SD, Schwartz MJ, et al. A Hospital Is Not Just a Factory, but a Complex Adaptive System-Implications for Perioperative Care. Anesth Analg. 2017;125(1):333-341. doi:10.1213/ANE.000000…

9858. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34732/psn-pdf
      May 09, 2015 - A Tale of Two Stories: Contrasting Views of Patient Safety. May 9, 2015 Cook RI, Woods DD, Miller C. Chicago, IL: National Patient Safety Foundation; 1997. https://psnet.ahrq.gov/issue/tale-two-stories-contrasting-views-patient-safety A report from a workshop, this document is a well-written look at the difference…

9859. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35467/psn-pdf
      March 11, 2011 - The impact of electronic health records on time efficiency of physicians and nurses: a systematic review. March 11, 2011 Poissant L, Pereira J, Tamblyn R, et al. The impact of electronic health records on time efficiency of physicians and nurses: a systematic review. J Am Med Inform Assoc. 2005;12(5):505-16. https…

9860. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867177/psn-pdf
      January 01, 2025 - Experiences with diagnostic delay among underserved racial and ethnic patients: a systematic review of the qualitative literature. November 20, 2024 Faugno E, Galbraith AA, Walsh KE, et al. Experiences with diagnostic delay among underserved racial and ethnic patients: a systematic review of the qualitative litera…