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psnet.ahrq.gov/node/34796/psn-pdf
November 18, 2015 - The business case for quality: case studies and an
analysis.
November 18, 2015
Leatherman S, Berwick DM, Iles D, et al. The business case for quality: case studies and an analysis.
Health Aff (Millwood). 2003;22(2):17-30.
https://psnet.ahrq.gov/issue/business-case-quality-case-studies-and-analysis
This comprehens…
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psnet.ahrq.gov/node/50916/psn-pdf
February 19, 2020 - Patient safety and suicide prevention in mental health
services: time for a new paradigm?
February 19, 2020
Quinlivan L, Littlewood DL, Webb RT, et al. Patient safety and suicide prevention in mental health services:
time for a new paradigm? J Mental Health. 2020;29(1):1-5. doi:10.1080/09638237.2020.1714013.
https…
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psnet.ahrq.gov/issue/ashrm-patient-safety-portal
September 27, 2016 - Multi-use Website
ASHRM Patient Safety Portal.
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March 21, 2012
This Web site provides access to educational resources for risk ma…
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psnet.ahrq.gov/node/47802/psn-pdf
March 04, 2019 - The path to diagnostic excellence includes feedback to
calibrate how clinicians think.
March 4, 2019
Meyer AND, Singh H. The Path to Diagnostic Excellence Includes Feedback to Calibrate How Clinicians
Think. JAMA. 2019;321(8):737-738. doi:10.1001/jama.2019.0113.
https://psnet.ahrq.gov/issue/path-diagnostic-excelle…
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psnet.ahrq.gov/node/44621/psn-pdf
February 10, 2016 - Young surgeons on speaking up: when and how surgical
trainees voice concerns about supervisors' clinical
decisions.
February 10, 2016
Sur MD, Schindler N, Singh P, et al. Young surgeons on speaking up: when and how surgical trainees
voice concerns about supervisors' clinical decisions. Am J Surg. 2016;211(2):437-4…
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psnet.ahrq.gov/node/40546/psn-pdf
September 29, 2017 - Tragedy into policy: a quantitative study of nurses'
attitudes toward patient advocacy activities.
September 29, 2017
Black LM. Tragedy into policy: a quantitative study of nurses' attitudes toward patient advocacy activities.
Am J Nurs. 2011;111(6):26-37. doi:10.1097/01.NAJ.0000398537.06542.c0.
https://psnet.ahrq…
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psnet.ahrq.gov/node/50932/psn-pdf
February 26, 2020 - Clinician-directed performance improvement: moving
beyond externally mandated metrics.
February 26, 2020
Goitein L. Clinician-directed performance improvement: moving beyond externally mandated metrics.
Health Aff (Millwood). 2020;39(2). doi:10.1377/hlthaff.2019.00505.
https://psnet.ahrq.gov/issue/clinician-direct…
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psnet.ahrq.gov/node/43660/psn-pdf
November 12, 2014 - Developing a systematic approach to safer medication
use during pregnancy: summary of a Centers for Disease
Control and Prevention–convened meeting.
November 12, 2014
Broussard CS, Frey MT, Hernandez-Diaz S, et al. Developing a systematic approach to safer medication
use during pregnancy: summary of a Centers for …
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psnet.ahrq.gov/node/46473/psn-pdf
December 18, 2017 - Diagnostic errors: impact of an educational intervention
on pediatric primary care.
December 18, 2017
Walsh JN, Knight M, Lee AJ. Diagnostic Errors: Impact of an Educational Intervention on Pediatric Primary
Care. Journal of Pediatric Health Care. 2017;32(1). doi:10.1016/j.pedhc.2017.07.004.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/45172/psn-pdf
January 01, 2017 - Strategies for developing and recognizing faculty working
in quality improvement and patient safety.
December 30, 2016
Coleman DL, Wardrop RM, Levinson WS, et al. Strategies for Developing and Recognizing Faculty
Working in Quality Improvement and Patient Safety. Acad Med. 2017;92(1):52-57.
doi:10.1097/ACM.0000000…
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psnet.ahrq.gov/node/47429/psn-pdf
December 05, 2018 - The Fearless Organization: Creating Psychological Safety
in the Workplace for Learning, Innovation, and Growth.
December 5, 2018
Edmondson AC. Hoboken, NJ: John Wiley & Sons, Inc.; 2019. ISBN: 9781119477266.
https://psnet.ahrq.gov/issue/fearless-organization-creating-psychological-safety-workplace-learning-
innova…
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psnet.ahrq.gov/node/43398/psn-pdf
July 30, 2014 - Strategies to prevent healthcare-associated infections
through hand hygiene.
July 30, 2014
Ellingson K, Haas JP, Aiello AE, et al. Strategies to prevent healthcare-associated infections through hand
hygiene. Infect Control Hosp Epidemiol. 2014;35(8):937-960. doi:10.1086/677145.
https://psnet.ahrq.gov/issue/strateg…
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psnet.ahrq.gov/node/60155/psn-pdf
March 25, 2020 - Analysis of patient-physician concordance in the
understanding of chemotherapy treatment plans among
patients with cancer.
March 25, 2020
Almalki H, Absi A, Alghamdi A, et al. Analysis of patient-physician concordance in the understanding of
chemotherapy treatment plans among patients with cancer. JAMA Netw Open. …
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psnet.ahrq.gov/node/43468/psn-pdf
December 10, 2014 - Does compliance to patient safety tasks improve and
sustain when radiotherapy treatment processes are
standardized?
December 10, 2014
Simons P, Houben R, Benders J, et al. Does compliance to patient safety tasks improve and sustain when
radiotherapy treatment processes are standardized? Eur J Oncol Nurs. 2014;18(5…
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psnet.ahrq.gov/node/837201/psn-pdf
May 25, 2022 - Near miss research in the healthcare system: a scoping
review.
May 25, 2022
Feng T-ting, Zhang X, Tan L-ling, et al. Near miss research in the healthcare system: a scoping review. J
Nurs Adm. 2022;52(3):160-166. doi:10.1097/nna.0000000000001124.
https://psnet.ahrq.gov/issue/near-miss-research-healthcare-system-sco…
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psnet.ahrq.gov/node/45349/psn-pdf
July 27, 2016 - An insurer's care transition program emphasizes
medication reconciliation, reduces readmissions and
costs.
July 27, 2016
Polinski JM, Moore JM, Kyrychenko P, et al. An Insurer's Care Transition Program Emphasizes Medication
Reconciliation, Reduces Readmissions And Costs. Health Aff (Millwood). 2016;35(7):1222-9.
…
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psnet.ahrq.gov/node/44619/psn-pdf
November 04, 2015 - Seeing through Google Glass: using an innovative
technology to improve medication safety behaviors in
undergraduate nursing students.
November 4, 2015
Schneidereith T. Seeing Through Google Glass: Using an Innovative Technology to Improve Medication
Safety Behaviors in Undergraduate Nursing Students. Nurs Educ Per…
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psnet.ahrq.gov/node/836718/psn-pdf
March 09, 2022 - Systems engineering analysis of diagnostic referral
closed-loop processes.
March 9, 2022
Nehls N, Yap TS, Salant T, et al. Systems engineering analysis of diagnostic referral closed-loop
processes. BMJ Open Qual. 2021;10(4):e001603. doi:10.1136/bmjoq-2021-001603.
https://psnet.ahrq.gov/issue/systems-engineering-an…
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psnet.ahrq.gov/node/34662/psn-pdf
December 24, 2008 - User's manual for the IOM's 'Quality Chasm' report.
December 24, 2008
Berwick DM. A user's manual for the IOM's 'Quality Chasm' report. Health Aff (Millwood). 2002;21(3):80-90.
https://psnet.ahrq.gov/issue/users-manual-ioms-quality-chasm-report
Fifteen months after releasing its report on patient safety (To Err Is …
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psnet.ahrq.gov/node/45670/psn-pdf
November 16, 2016 - Not thinking clearly? Play a game, seriously!
November 16, 2016
Mohan D, Schell J, Angus DC. Not Thinking Clearly? Play a Game, Seriously!. JAMA. 2016;316(18):1867-
1868. doi:10.1001/jama.2016.14174.
https://psnet.ahrq.gov/issue/not-thinking-clearly-play-game-seriously
Heuristics enable experts to build off their …