AHRQ Search | Home Page

Managing clinical failure: a complex adaptive system perspective. | PSNet

psnet.ahrq.gov/issue/managing-clinical-failure-complex-adaptive-system-perspective

August 13, 2014 - Study Managing clinical failure: a complex adaptive system perspective. Citation Text: Matthews JI, Thomas PT. Managing clinical failure: a complex adaptive system perspective. Int J Health Care Qual Assur. 2007;20(3):184-194. doi:10.1108/09526860710743336. Copy Citation Format: …

Teaching but not learning: how medical residency programs handle errors. | PSNet

psnet.ahrq.gov/issue/teaching-not-learning-how-medical-residency-programs-handle-errors

December 18, 2008 - Study Teaching but not learning: how medical residency programs handle errors. Citation Text: Hoff T, Pohl H, Bartfield J. Teaching but not learning: how medical residency programs handle errors. J Organ Behav. 2006;27(7). doi:10.1002/job.395. Copy Citation Format: DOI Go…

From blaming to learning: re-framing organisational learning from adverse incidents. | PSNet

psnet.ahrq.gov/issue/blaming-learning-re-framing-organisational-learning-adverse-incidents

October 05, 2022 - Study From blaming to learning: re-framing organisational learning from adverse incidents. Citation Text: Gray D, Williams S. From blaming to learning: re‐framing organisational learning from adverse incidents. Learn Org. 2011;18(6):438-453. doi:10.1108/09696471111171295. Copy Citatio…

Social risk, health inequity, and patient safety. | PSNet

psnet.ahrq.gov/issue/social-risk-health-inequity-and-patient-safety

September 28, 2022 - Commentary Social risk, health inequity, and patient safety. Citation Text: Boisvert S. Social risk, health inequity, and patient safety. J Healthc Risk Manag. 2022;42(2):18-25. doi:10.1002/jhrm.21519. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7…

Use of a surgical safety checklist to improve team communication. | PSNet

psnet.ahrq.gov/issue/use-surgical-safety-checklist-improve-team-communication

August 08, 2018 - Commentary Use of a surgical safety checklist to improve team communication. Citation Text: Cabral RA, Eggenberger T, Keller K, et al. Use of a surgical safety checklist to improve team communication. AORN J. 2016;104(3):206-216. doi:10.1016/j.aorn.2016.06.019. Copy Citation Format…

Using improvement science methods to increase accuracy of surgical consents. | PSNet

psnet.ahrq.gov/issue/using-improvement-science-methods-increase-accuracy-surgical-consents

October 05, 2011 - Study Using improvement science methods to increase accuracy of surgical consents. Citation Text: Mercurio P, Ellis AS, Schoettker PJ, et al. Using improvement science methods to increase accuracy of surgical consents. AORN J. 2014;100(1):42-53. doi:10.1016/j.aorn.2013.07.023. Copy Cit…

Improving communication of diagnostic uncertainty to families of hospitalized children. | PSNet

psnet.ahrq.gov/issue/improving-communication-diagnostic-uncertainty-families-hospitalized-children

December 23, 2020 - Study Improving communication of diagnostic uncertainty to families of hospitalized children. Citation Text: Young EE, Kane J, Timmons K, et al. Improving communication of diagnostic uncertainty to families of hospitalized children. Diagnosis (Berl). 2024;11(2):186-191. doi:10.1515/dx-20…

Measurement of quality and assurance of safety in the critically ill. | PSNet

psnet.ahrq.gov/issue/measurement-quality-and-assurance-safety-critically-ill

March 21, 2012 - Commentary Measurement of quality and assurance of safety in the critically ill. Citation Text: Pronovost P, Sexton B, Pham JC, et al. Measurement of quality and assurance of safety in the critically ill. Clin Chest Med. 2009;30(1):169-79, x. doi:10.1016/j.ccm.2008.09.004. Copy Citat…

How one medical checkup can snowball into a ‘cascade’ of tests, causing more harm than good. | PSNet

psnet.ahrq.gov/issue/how-one-medical-checkup-can-snowball-cascade-tests-causing-more-harm-good

February 03, 2021 - Newspaper/Magazine Article How one medical checkup can snowball into a ‘cascade’ of tests, causing more harm than good. Citation Text: How one medical checkup can snowball into a ‘cascade’ of tests, causing more harm than good. Ganguli I. Washington Post. January 5, 2020. Copy Citati…

Improving diagnostic decision support through deliberate reflection: a proposal. | PSNet

psnet.ahrq.gov/issue/improving-diagnostic-decision-support-through-deliberate-reflection-proposal

September 23, 2020 - Commentary Improving diagnostic decision support through deliberate reflection: a proposal. Citation Text: Schmidt HG, Mamede S. Improving diagnostic decision support through deliberate reflection: a proposal. Diagnosis (Berl). 2023;10(1):38-42. doi:10.1515/dx-2022-0062. Copy Citation …

Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented plans. | PSNet

psnet.ahrq.gov/issue/improving-safety-culture-results-rhode-island-icus-lessons-learned-development-action

September 17, 2010 - Study Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented plans. Citation Text: Vigorito MC, McNicoll L, Adams L, et al. Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-orie…

Artificial intelligence systems for complex decision-making in acute care medicine: a review. | PSNet

psnet.ahrq.gov/issue/artificial-intelligence-systems-complex-decision-making-acute-care-medicine-review

March 16, 2011 - Review Emerging Classic Artificial intelligence systems for complex decision-making in acute care medicine: a review. Citation Text: Lynn LA. Artificial intelligence systems for complex decision-making in acute care medicine: a review. Patient Saf Surg. 2019;13:…

Medical emergency teams: a strategy for improving patient care and nursing work environments. | PSNet

psnet.ahrq.gov/issue/medical-emergency-teams-strategy-improving-patient-care-and-nursing-work-environments

March 24, 2011 - Study Medical emergency teams: a strategy for improving patient care and nursing work environments. Citation Text: Galhotra S, Scholle CC, Dew MA, et al. Medical emergency teams: a strategy for improving patient care and nursing work environments. J Adv Nurs. 2006;55(2):180-7. Copy C…

The problem with Plan-Do-Study-Act cycles. | PSNet

psnet.ahrq.gov/issue/problem-plan-do-study-act-cycles

June 26, 2019 - Commentary The problem with Plan-Do-Study-Act cycles. Citation Text: Reed JE, Card AJ. The problem with Plan-Do-Study-Act cycles. BMJ Qual Saf. 2016;25(3):147-52. doi:10.1136/bmjqs-2015-005076. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 …

Recommendations and low-technology safety solutions following neuromuscular blocking agent incidents. | PSNet

psnet.ahrq.gov/issue/recommendations-and-low-technology-safety-solutions-following-neuromuscular-blocking-agent

October 02, 2024 - Commentary Recommendations and low-technology safety solutions following neuromuscular blocking agent incidents. Citation Text: Graudins L, Downey G, Bui T, et al. Recommendations and Low-Technology Safety Solutions Following Neuromuscular Blocking Agent Incidents. Jt Comm J Qual Patient…

She hoped to shine a light on maternal mortality among Native Americans. Instead, she became a statistic of it. | PSNet

psnet.ahrq.gov/issue/she-hoped-shine-light-maternal-mortality-among-native-americans-instead-she-became-statistic

July 22, 2020 - Newspaper/Magazine Article She hoped to shine a light on maternal mortality among Native Americans. Instead, she became a statistic of it. Citation Text: She hoped to shine a light on maternal mortality among Native Americans. Instead, she became a statistic of it. Chuck E, Assefa H. N…

The risk of adverse drug events and hospital-related morbidity and mortality among older adults with potentially inappropriate medication use. | PSNet

psnet.ahrq.gov/issue/risk-adverse-drug-events-and-hospital-related-morbidity-and-mortality-among-older-adults

October 10, 2012 - Study The risk of adverse drug events and hospital-related morbidity and mortality among older adults with potentially inappropriate medication use. Citation Text: Page RL, Ruscin M. The risk of adverse drug events and hospital-related morbidity and mortality among older adults with po…

Building safer systems by ecological design: using restoration science to develop a medication safety intervention. | PSNet

psnet.ahrq.gov/issue/building-safer-systems-ecological-design-using-restoration-science-develop-medication-safety

February 14, 2024 - Study Building safer systems by ecological design: using restoration science to develop a medication safety intervention. Citation Text: Marck PB, Kwan JA, Preville B, et al. Building safer systems by ecological design: using restoration science to develop a medication safety intervent…

Advancement toward High Reliability in Healthcare Awards. | PSNet

psnet.ahrq.gov/issue/advancement-toward-high-reliability-healthcare-awards

June 08, 2011 - January 21, 2009 Teamwork is associated with reduced hospital staff burnout at military

Fatal drug mix-up exposes hospital flaws. | PSNet

psnet.ahrq.gov/issue/fatal-drug-mix-exposes-hospital-flaws

March 02, 2016 - July 10, 2018 Teamwork is associated with reduced hospital staff burnout at military

Search AHRQ

Results