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psnet.ahrq.gov/node/61057/psn-pdf
October 28, 2020 - Improving Diagnostic Quality and Safety/Reducing
Diagnostic Error: Measurement Considerations. Final
Report
October 28, 2020
Washington DC; National Quality Forum: October 6, 2020.
https://psnet.ahrq.gov/issue/improving-diagnostic-quality-and-safetyreducing-diagnostic-error-
measurement-considerations
With input…
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psnet.ahrq.gov/node/50865/psn-pdf
February 05, 2020 - Understanding principles of high reliability organizations
through the eyes of VIONE: a clinical program to improve
patient safety by deprescribing potentially inappropriate
medications and reducing polypharmacy.
February 5, 2020
Battar S, Dickerson KRW, Sedgwick C, et al. Understanding principles of high reliabil…
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psnet.ahrq.gov/node/866902/psn-pdf
October 09, 2024 - Why do acute healthcare staff behave unprofessionally
towards each other and how can these behaviours be
reduced? A realist review.
October 9, 2024
Aunger JA, Abrams R, Westbrook JI, et al. Why do acute healthcare staff behave unprofessionally towards
each other and how can these behaviours be reduced? A realist r…
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psnet.ahrq.gov/node/845301/psn-pdf
March 01, 2023 - Evaluation of effectiveness and safety of pharmacist
independent prescribers in care homes: cluster
randomised controlled trial.
March 1, 2023
Holland R, Bond CM, Alldred DP, et al. Evaluation of effectiveness and safety of pharmacist independent
prescribers in care homes: cluster randomised controlled trial. BMJ.…
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psnet.ahrq.gov/node/38572/psn-pdf
April 22, 2009 - Development and validation of the SURgical PAtient
Safety System (SURPASS) checklist.
April 22, 2009
de Vries EN, Hollmann MW, Smorenburg SM, et al. Development and validation of the SURgical PAtient
Safety System (SURPASS) checklist. Qual Saf Health Care. 2009;18(2):121-6.
doi:10.1136/qshc.2008.027524.
https://p…
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psnet.ahrq.gov/node/44768/psn-pdf
February 03, 2016 - Recommendations and low-technology safety solutions
following neuromuscular blocking agent incidents.
February 3, 2016
Graudins L, Downey G, Bui T, et al. Recommendations and Low-Technology Safety Solutions Following
Neuromuscular Blocking Agent Incidents. Jt Comm J Qual Patient Saf. 2016;42(2):86-91.
https://psne…
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psnet.ahrq.gov/node/837200/psn-pdf
May 25, 2022 - Analysis of readmissions in a mobile integrated health
transitional care program using root cause analysis and
common cause analysis.
May 25, 2022
Buitrago I, Seidl KL, Gingold DB, et al. Analysis of readmissions in a mobile integrated health transitional
care program using root cause analysis and common cause ana…
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psnet.ahrq.gov/issue/human-factors-and-medical-devices
July 31, 2012 - Multi-use Website
Human Factors and Medical Devices.
Citation Text:
Human Factors and Medical Devices. Center for Devices and Radiological Health, US Food and Drug Administration.
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psnet.ahrq.gov/issue/science-interruption
September 04, 2024 - Commentary
The science of interruption.
Citation Text:
Coiera E. The science of interruption. BMJ Qual Saf. 2012;21(5):357-60. doi:10.1136/bmjqs-2012-000783.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/issue/side-tracks-safety-express-interruptions-lead-errors-and-unfinishedwait-what-was-i-doing
June 10, 2018 - Newspaper/Magazine Article
Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing?
Citation Text:
Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing? ISMP Medication Safety Alert! Acute care…
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psnet.ahrq.gov/issue/diversion-threat-patient-safety-adopting-best-practices
April 20, 2022 - Webinar
Diversion is a Threat to Patient Safety: Adopting Best Practices.
Citation Text:
Diversion is a Threat to Patient Safety: Adopting Best Practices. Institute for Safe Medication Practices. April 6, 2022.
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psnet.ahrq.gov/issue/eliminating-racial-and-ethnic-disparities-causing-mortality-and-morbidity-pregnant-and
December 23, 2016 - Sentinel Event Alerts
Eliminating racial and ethnic disparities causing mortality and morbidity in pregnant and postpartum patients.
Citation Text:
Eliminating racial and ethnic disparities causing mortality and morbidity in pregnant and postpartum patients. Sentinel Event Alert. January…
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psnet.ahrq.gov/issue/reducing-risk-designing-safer-shame-free-health-care-environment
September 29, 2017 - Book/Report
Reducing the Risk by Designing a Safer, Shame-free Health Care Environment.
Citation Text:
Reducing the Risk by Designing a Safer, Shame-free Health Care Environment. Abrams MA, Hung LL, Kashuba AB, et al. Chicago, IL: American Medical Association; 2007.
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psnet.ahrq.gov/issue/well-being-playbook-20-covid-19-resource-hospital-and-health-system-leaders
July 21, 2021 - Tools/Toolkit
Well-Being Playbook 2.0. A COVID-19 Resource for Hospital and Health System Leaders.
Citation Text:
Well-Being Playbook 2.0. A COVID-19 Resource for Hospital and Health System Leaders. AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021.
…
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psnet.ahrq.gov/issue/improving-diagnostic-quality-safetyreducing-diagnostic-error-measurement-considerations
November 20, 2019 - Book/Report
Improving Diagnostic Quality & Safety/Reducing Diagnostic Error: Measurement Considerations.
Citation Text:
Improving Diagnostic Quality & Safety/Reducing Diagnostic Error: Measurement Considerations. Washington DC; National Quality Forum: October 28, 2019.
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psnet.ahrq.gov/issue/findings-two-inaugural-leapfrog-surveys-2019
November 06, 2019 - Book/Report
Findings of Two Inaugural Leapfrog Surveys 2019.
Citation Text:
Findings of Two Inaugural Leapfrog Surveys 2019. Washington DC: Leapfrog Group; 2019.
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psnet.ahrq.gov/node/40674/psn-pdf
October 16, 2012 - The care transitions intervention: translating from
efficacy to effectiveness.
October 16, 2012
Voss R, Gardner R, Baier R, et al. The care transitions intervention: translating from efficacy to
effectiveness. Arch Intern Med. 2011;171(14):1232-7. doi:10.1001/archinternmed.2011.278.
https://psnet.ahrq.gov/issue/ca…
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psnet.ahrq.gov/node/36255/psn-pdf
February 02, 2011 - Interns' compliance with Accreditation Council for
Graduate Medical Education work-hour limits.
February 2, 2011
Landrigan CP, Barger LK, Cade BE, et al. Interns' compliance with accreditation council for graduate
medical education work-hour limits. JAMA. 2006;296(9):1063-70.
https://psnet.ahrq.gov/issue/interns-c…
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psnet.ahrq.gov/node/837729/psn-pdf
July 27, 2022 - Development of a multicomponent intervention to
decrease racial bias among healthcare staff.
July 27, 2022
Tajeu GS, Juarez L, Williams JH, et al. Development of a multicomponent intervention to decrease racial
bias among healthcare staff. J Gen Intern Med. 2022;37(8):1970-1979. doi:10.1007/s11606-022-07464-x.
htt…
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psnet.ahrq.gov/node/39670/psn-pdf
July 07, 2010 - The Power of Safety: State Reporting Provides Lessons in
Reducing Harm, Improving Care.
July 7, 2010
Washington DC: National Quality Forum; 2010.
https://psnet.ahrq.gov/issue/power-safety-state-reporting-provides-lessons-reducing-harm-improving-care
The landmark Institute of Medicine (IOM) report, To Err Is Human,…