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psnet.ahrq.gov/issue/swiss-cheese-model-adverse-event-occurrence-closing-holes
September 25, 2024 - Commentary
The Swiss cheese model of adverse event occurrence—closing the holes.
Citation Text:
Stein JE, Heiss K. The Swiss cheese model of adverse event occurrence--Closing the holes. Semin Pediatr Surg. 2015;24(6):278-82. doi:10.1053/j.sempedsurg.2015.08.003.
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psnet.ahrq.gov/issue/faultno-fault-bearing-brunt-medical-mishaps
January 27, 2021 - Commentary
Fault/no fault: bearing the brunt of medical mishaps.
Citation Text:
Silversides A. Fault/no fault: bearing the brunt of medical mishaps. CMAJ. 2008;179(4):309-11. doi:10.1503/cmaj.081020.
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psnet.ahrq.gov/issue/reducing-medication-errors-using-applied-technology
January 07, 2011 - Commentary
Reducing medication errors by using applied technology.
Citation Text:
Caesar BR, Hutchinson B. Reducing medication errors by using applied technology. Nursing (Brux). 2006;36(8):24-25.
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psnet.ahrq.gov/issue/defensive-medicine-it-time-finally-slow-down-epidemic
November 18, 2016 - Commentary
Emerging Classic
Defensive medicine: it is time to finally slow down an epidemic.
Citation Text:
Vento S, Cainelli F, Vallone A. Defensive medicine: It is time to finally slow down an epidemic. World J Clin Cases. 2018;6(11):406-409. doi:10.12998/wjcc…
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psnet.ahrq.gov/issue/development-self-report-instrument-measure-patient-safety-attitudes-skills-and-knowledge
April 10, 2013 - Commentary
Development of a self-report instrument to measure patient safety attitudes, skills, and knowledge.
Citation Text:
Schnall R, Stone PW, Currie L, et al. Development of a self-report instrument to measure patient safety attitudes, skills, and knowledge. J Nurs Scholarsh. 2008…
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psnet.ahrq.gov/issue/or-and-just-culture
February 01, 2017 - Commentary
The OR and a "just culture."
Citation Text:
Hamlin L. The OR and a "just culture". AORN J. 2009;90(4):495-498. doi:10.1016/j.aorn.2009.09.003.
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psnet.ahrq.gov/issue/development-infusion-pump-safety-score
January 06, 2017 - Commentary
Development of an "infusion pump safety score".
Citation Text:
Carlson R, Johnson B, Ensign RH. Development of an "infusion pump safety score". Am J Health Syst Pharm. 2015;72(10):777-9. doi:10.2146/ajhp140421.
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psnet.ahrq.gov/issue/impact-feeling-responsible-adverse-events-doctors-personal-and-professional-lives-importance
March 13, 2013 - Study
Impact of feeling responsible for adverse events on doctors' personal and professional lives: the importance of being open to criticism from colleagues.
Citation Text:
Aasland OG, Førde R. Impact of feeling responsible for adverse events on doctors' personal and professional live…
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psnet.ahrq.gov/issue/antecedents-willingness-report-medical-treatment-errors-health-care-organizations-multilevel
May 06, 2015 - Commentary
Antecedents of willingness to report medical treatment errors in health care organizations: a multilevel theoretical framework.
Citation Text:
Naveh E, Katz-Navon T. Antecedents of willingness to report medical treatment errors in health care organizations: a multilevel theo…
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psnet.ahrq.gov/issue/john-m-eisenberg-patient-safety-awards-research-david-w-bates-md-msc-brigham-and-womens
July 25, 2018 - Commentary
John M. Eisenberg Patient Safety Awards. Research: David W. Bates, MD, MSc, Brigham and Women's Hospital.
Citation Text:
Bates DW. John M. Eisenberg Patient Safety Awards. Research: David W. Bates, MD, MSc, Brigham and Women's Hospital. Interview by Steven Berman. Jt Comm J Q…
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psnet.ahrq.gov/issue/medical-error-and-systems-signaling-conceptual-and-linguistic-definition
July 12, 2019 - Commentary
Medical error and systems of signaling: conceptual and linguistic definition.
Citation Text:
Smorti A, Cappelli F, Zarantonello R, et al. Medical error and systems of signaling: conceptual and linguistic definition. Intern Emerg Med. 2014;9(6):681-8. doi:10.1007/s11739-014-110…
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psnet.ahrq.gov/issue/changing-medical-malpractice-system-align-what-we-know-about-patient-safety-and-quality
September 20, 2012 - Commentary
Changing the medical malpractice system to align with what we know about patient safety and quality improvement.
Citation Text:
Sklar DP. Changing the Medical Malpractice System to Align With What We Know About Patient Safety and Quality Improvement. Acad Med. 2017;92(7):891-8…
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psnet.ahrq.gov/issue/2014-guide-state-adverse-event-reporting-systems
November 29, 2009 - Book/Report
2014 Guide to State Adverse Event Reporting Systems.
Citation Text:
2014 Guide to State Adverse Event Reporting Systems. Hanlon C, Sheedy K, Kniffin T, Rosenthal J. Portland, ME: National Academy for State Health Policy; 2015.
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psnet.ahrq.gov/issue/practical-application-high-reliability-principles-healthcare-optimize-quality-and-safety
August 14, 2024 - Commentary
Practical application of high-reliability principles in healthcare to optimize quality and safety outcomes.
Citation Text:
Oster CA, Deakins S. Practical Application of High-Reliability Principles in Healthcare to Optimize Quality and Safety Outcomes. J Nurs Admin. 2017;48(1):…
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psnet.ahrq.gov/issue/perspective-beyond-counting-hours-importance-supervision-professionalism-transitions-care-and
September 20, 2011 - Commentary
Perspective: beyond counting hours: the importance of supervision, professionalism, transitions of care, and workload in residency training.
Citation Text:
Schumacher D, Slovin SR, Riebschleger MP, et al. Perspective. Academic Medicine. 2012;87(7). doi:10.1097/acm.0b013e318257…
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www.ahrq.gov/patient-safety/reports/engage/model-in-pc.html
March 01, 2017 - Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families
Model of Patient Safety in Primary Care
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Table of Contents
Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families
Executive Summary
Introduc…
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psnet.ahrq.gov/issue/alternative-perspectives-safety-home-delivered-health-care-sequential-exploratory-mixed
February 17, 2016 - Study
Alternative perspectives of safety in home delivered health care: a sequential exploratory mixed method study.
Citation Text:
Jones S. Alternative perspectives of safety in home delivered health care: a sequential exploratory mixed method study. J Adv Nurs. 2016;72(10):2536-46. doi…
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psnet.ahrq.gov/issue/impact-nurse-peer-review-culture-safety
November 29, 2023 - Commentary
Impact of nurse peer review on a culture of safety.
Citation Text:
Herrington CR, Hand MW. Impact of Nurse Peer Review on a Culture of Safety. J Nurs Care Qual. 2019;34(2):158-162. doi:10.1097/NCQ.0000000000000361.
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psnet.ahrq.gov/issue/impact-nursing-hospital-patient-mortality-focused-review-and-related-policy-implications
September 21, 2011 - Review
Impact of nursing on hospital patient mortality: a focused review and related policy implications.
Citation Text:
Tourangeau AE, Cranley LA, Jeffs L. Impact of nursing on hospital patient mortality: a focused review and related policy implications. Qual Saf Health Care. 2006;15(…
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psnet.ahrq.gov/issue/different-roles-same-goal-risk-and-quality-management-partnering-patient-safety-ashrm
January 27, 2021 - Book/Report
Different roles, same goal: risk and quality management partnering for patient safety. By the ASHRM Monographs Task Force.
Citation Text:
Bokar V, Perry DG. Different Roles, Same Goal: Risk And Quality Management Partnering For Patient Safety. By The Ashrm Monographs Task Fo…