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psnet.ahrq.gov/node/41546/psn-pdf
December 29, 2014 - Using a logic model to design and evaluate quality and
patient safety improvement programs.
December 29, 2014
Goeschel CA, Weiss WM, Pronovost P. Using a logic model to design and evaluate quality and patient
safety improvement programs. Int J Qual Health Care. 2012;24(4):330-7. doi:10.1093/intqhc/mzs029.
https://…
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psnet.ahrq.gov/node/45094/psn-pdf
May 04, 2016 - Actions Needed to Improve Newly Enrolled Veterans'
Access to Primary Care.
May 4, 2016
Washington, DC: United States Government Accountability Office; March 18, 2016. Publication GAO-16-
328.
https://psnet.ahrq.gov/issue/actions-needed-improve-newly-enrolled-veterans-access-primary-care
This analysis found that s…
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psnet.ahrq.gov/node/48028/psn-pdf
August 28, 2019 - Error Reduction and Prevention in Surgical Pathology,
Second Edition.
August 28, 2019
Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636.
https://psnet.ahrq.gov/issue/error-reduction-and-prevention-surgical-pathology-2nd-edition
Surgical specimen and laboratory process proble…
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psnet.ahrq.gov/node/838137/psn-pdf
September 21, 2022 - How insight contributes to diagnostic excellence.
September 21, 2022
Shimizu T, Graber ML. How insight contributes to diagnostic excellence. Diagnosis (Berl). 2022;9(3):311-
315. doi:10.1515/dx-2022-0007.
https://psnet.ahrq.gov/issue/how-insight-contributes-diagnostic-excellence
Improving diagnostic reasoning skil…
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psnet.ahrq.gov/node/74186/psn-pdf
January 01, 2022 - Staffing, teamwork and scope of practice: analysis of the
association with patient safety in the context of
rehabilitation.
December 15, 2021
Jomaa C, Dubois C?A, Caron I, et al. Staffing, teamwork and scope of practice: analysis of the association
with patient safety in the context of rehabilitation. J Adv Nurs. …
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psnet.ahrq.gov/node/74724/psn-pdf
February 02, 2022 - Using smart IV infusion pumps outside of patient rooms.
February 2, 2022
Messing EG, Abraham RS, Quinn NJ, et al. Using smart IV infusion pumps outside of patient rooms. Am J
Nurs. 2022;122(2). doi:10.1097/01.naj.0000819772.45006.5d.
https://psnet.ahrq.gov/issue/using-smart-iv-infusion-pumps-outside-patient-rooms
…
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psnet.ahrq.gov/node/72813/psn-pdf
March 10, 2021 - Racial/ethnic inequities in pregnancy-related morbidity
and mortality.
March 10, 2021
Minehart RD, Bryant AS, Jackson J, et al. Racial/ethnic inequities in pregnancy-related morbidity and
mortality. Obstet Gynecol Clin North Am. 2021;48(1):31-51. doi:10.1016/j.ogc.2020.11.005.
https://psnet.ahrq.gov/issue/racialet…
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psnet.ahrq.gov/node/840163/psn-pdf
November 16, 2022 - Deep Dive: Racial and Ethnic Disparities in Health and
Healthcare.
November 16, 2022
Plymouth Meeting, PA: ECRI and the Institute for Safe Medication Practices; 2022.
https://psnet.ahrq.gov/issue/deep-dive-racial-and-ethnic-disparities-health-and-healthcare
Racist behavior directed at either patients or clinicians…
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psnet.ahrq.gov/node/45035/psn-pdf
January 23, 2017 - Premature closure? Not so fast.
January 23, 2017
Dhaliwal G. Premature closure? Not so fast. BMJ Qual Saf. 2017;26(2):87-89. doi:10.1136/bmjqs-2016-
005267.
https://psnet.ahrq.gov/issue/premature-closure-not-so-fast
Analyzing clinician decision making is increasingly suggested as a strategy to reduce diagnostic er…
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psnet.ahrq.gov/node/47514/psn-pdf
October 31, 2018 - Making Hospitals Safe for People With Diabetes.
October 31, 2018
Watts E, Rayman G. Diabetes UK. London, UK; 2018.
https://psnet.ahrq.gov/issue/making-hospitals-safe-people-diabetes
Chronic disease management can add complexity to inpatient care regimens. Researchers worked with
patients, system leaders, and clini…
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psnet.ahrq.gov/node/44712/psn-pdf
December 09, 2015 - The effect of contact precautions on frequency of hospital
adverse events.
December 9, 2015
Croft LD, Liquori M, Ladd J, et al. The Effect of Contact Precautions on Frequency of Hospital Adverse
Events. Infect Control Hosp Epidemiol. 2015;36(11):1268-74. doi:10.1017/ice.2015.192.
https://psnet.ahrq.gov/issue/effec…
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psnet.ahrq.gov/node/837695/psn-pdf
July 20, 2022 - Narrowing the mindware gap in medicine.
July 20, 2022
Croskerry P. Narrowing the mindware gap in medicine. Diagnosis (Berl). 2022;9(2):176-183.
doi:10.1515/dx-2020-0128.
https://psnet.ahrq.gov/issue/narrowing-mindware-gap-medicine
In dual process thinking, Type 1 decisions are made rapidly, but can result in diagn…
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psnet.ahrq.gov/node/74011/psn-pdf
October 27, 2021 - Dashboards for visual display of patient safety data: a
systematic review.
October 27, 2021
Murphy DR, Savoy A, Satterly T, et al. Dashboards for visual display of patient safety data: a systematic
review. BMJ Health Care Inform. 2021;28(1):e100437. doi:10.1136/bmjhci-2021-100437.
https://psnet.ahrq.gov/issue/dash…
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psnet.ahrq.gov/node/46501/psn-pdf
March 20, 2018 - Blind obedience and an unnecessary workup for
hypoglycemia: a teachable moment.
March 20, 2018
Wang EY, Patrick L, Connor DM. Blind Obedience and an Unnecessary Workup for Hypoglycemia: A
Teachable Moment. JAMA Intern Med. 2018;178(2):279-280. doi:10.1001/jamainternmed.2017.7104.
https://psnet.ahrq.gov/issue/blind…
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psnet.ahrq.gov/node/47681/psn-pdf
January 30, 2019 - Infection prevention in the operating room anesthesia
work area.
January 30, 2019
Munoz-Price S, Bowdle A, Johnston L, et al. Infection prevention in the operating room anesthesia work
area. Infect Control Hosp Epidemiol. 2018:1-17. doi:10.1017/ice.2018.303.
https://psnet.ahrq.gov/issue/infection-prevention-operat…
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psnet.ahrq.gov/node/46640/psn-pdf
August 08, 2018 - IDEA4PS: the development of a research-oriented
learning healthcare system.
August 8, 2018
Moffatt-Bruce SD, Huerta T, Gaughan A, et al. IDEA4PS: The Development of a Research-Oriented
Learning Healthcare System. Am J Med Qual. 2018;33(4):420-425. doi:10.1177/1062860617751044.
https://psnet.ahrq.gov/issue/idea4ps-…
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psnet.ahrq.gov/node/844800/psn-pdf
September 25, 2019 - Patient Options for Safe and Effective Disposal of Unused
Opioids.
September 25, 2019
Washington, DC: United States Government Accountability Office; September 2019. Publication GAO-19-
650.
https://psnet.ahrq.gov/issue/patient-options-safe-and-effective-disposal-unused-opioids
One strategy to reduce the potentia…
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psnet.ahrq.gov/node/47881/psn-pdf
July 10, 2019 - Cognitive Errors and Diagnostic Mistakes: A Case-Based
Guide to Critical Thinking in Medicine.
July 10, 2019
Howard J. Cham, Switzerland: Springer Nature Switzerland; 2019. ISBN: 9783319932231.
https://psnet.ahrq.gov/issue/cognitive-errors-and-diagnostic-mistakes-case-based-guide-critical-thinking-
medicine
Cogni…
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psnet.ahrq.gov/node/43045/psn-pdf
August 02, 2015 - A multistep approach to improving biopsy site
identification in dermatology: physician, staff, and patient
roles based on a Delphi consensus.
August 2, 2015
Alam M, Lee A, Ibrahimi OA, et al. A multistep approach to improving biopsy site identification in
dermatology: physician, staff, and patient roles based on a…
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psnet.ahrq.gov/node/862613/psn-pdf
February 14, 2024 - Standardizing medication reconciliation in a pediatric
emergency department.
February 14, 2024
Sheth S, Bialostozky M, Hollenbach K, et al. Standardizing medication reconciliation in a pediatric
emergency department. Pediatrics. 2024;153(2):e2023061964. doi:10.1542/peds.2023-061964.
https://psnet.ahrq.gov/issue/st…