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psnet.ahrq.gov/node/49762/psn-pdf
June 01, 2016 - Despite the bureaucratic and political hurdles this presents,
providers in some regions have been able
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psnet.ahrq.gov/node/49698/psn-pdf
December 01, 2013 - Early
learnings have led
to adoption of
cross-continuum
teams in other
states and regions
as well
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psnet.ahrq.gov/web-mm/wrongful-resuscitation
October 12, 2012 - Regions with higher rates of DNH orders for persons with advanced dementia had fewer patients admitted
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psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
January 01, 2008 - In Conversation with…Jennifer Daley, MD
January 1, 2008
Also Read an Essay
Citation Text:
In Conversation with…Jennifer Daley, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Co…
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psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system
January 01, 2008 - Implementing a Patient Safety Program at a Large National Health System
Loran Hauck, MD, and Jan Jacob, MBA, RN | January 1, 2008
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Hauck LD, Jacob J. Implementing a Patient Safety …
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psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
May 01, 2008 - SPOTLIGHT CASE
A Painful Medication Reconciliation Mishap
Citation Text:
Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/issue/silence-power-and-communication-operating-room
June 08, 2011 - Study
Silence, power and communication in the operating room.
Citation Text:
Gardezi F, Lingard LA, Espin S, et al. Silence, power and communication in the operating room. J Adv Nurs. 2009;65(7):1390-1399. doi:10.1111/j.1365-2648.2009.04994.x.
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DOI Go…
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psnet.ahrq.gov/issue/racial-ethnic-and-socioeconomic-disparities-patient-safety-events-hospitalized-children
August 14, 2018 - Study
Racial, ethnic, and socioeconomic disparities in patient safety events for hospitalized children.
Citation Text:
Stockwell DC, Landrigan CP, Toomey SL, et al. Racial, Ethnic, and Socioeconomic Disparities in Patient Safety Events for Hospitalized Children. Hosp Pediatr. 2019;9(1):1…
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psnet.ahrq.gov/issue/understanding-knowledge-gaps-whistleblowing-and-speaking-health-care-narrative-reviews
September 11, 2018 - Book/Report
Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews.
Citation Text:
Understanding the knowledge gaps in whistleblowing and speaking up…
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psnet.ahrq.gov/issue/pharmacist-medication-reviews-improve-safety-monitoring-primary-care-patients
April 24, 2018 - Study
Pharmacist medication reviews to improve safety monitoring in primary care patients.
Citation Text:
Gallimore CE, Sokhal D, Schreiter EZ, et al. Pharmacist medication reviews to improve safety monitoring in primary care patients. Fam Syst Health. 2016;34(2):104-113. doi:10.1037/fsh…
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psnet.ahrq.gov/issue/challenging-authority-and-speaking-operating-room-environment-narrative-synthesis
December 13, 2017 - Review
Emerging Classic
Challenging authority and speaking up in the operating room environment: a narrative synthesis.
Citation Text:
Pattni N, Arzola C, Malavade A, et al. Challenging authority and speaking up in the operating room environment: a narrative syn…
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psnet.ahrq.gov/issue/relationship-organizational-culture-stress-satisfaction-and-burnout-physician-reported-error
October 12, 2011 - Study
The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study.
Citation Text:
Williams E, Manwell LB, Konrad TR, et al. The relationship of organizational culture, stress, satis…
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psnet.ahrq.gov/issue/cardiopulmonary-arrest-and-mortality-trends-and-their-association-rapid-response-system
January 15, 2009 - Study
Cardiopulmonary arrest and mortality trends, and their association with rapid response system expansion.
Citation Text:
Chen J, Ou L, Hillman KM, et al. Cardiopulmonary arrest and mortality trends, and their association with rapid response system expansion. Med J Aust. 2014;201(3):…
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psnet.ahrq.gov/issue/responsibility-quality-improvement-and-patient-safety-hospital-board-and-medical-staff
April 27, 2010 - Review
Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges.
Citation Text:
Goeschel CA, Wachter R, Pronovost P. Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challeng…
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psnet.ahrq.gov/issue/procedural-timeout-compliance-improved-real-time-clinical-decision-support
October 11, 2017 - Study
Procedural timeout compliance is improved with real-time clinical decision support.
Citation Text:
Shear T, Deshur M, Avram MJ, et al. Procedural Timeout Compliance Is Improved With Real-Time Clinical Decision Support. J Patient Saf. 2018;14(3):148-152. doi:10.1097/PTS.000000000000…
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psnet.ahrq.gov/issue/development-theoretical-framework-factors-affecting-patient-safety-incident-reporting
January 19, 2016 - Review
Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature.
Citation Text:
Archer S, Hull L, Soukup T, et al. Development of a theoretical framework of factors affecting patient safety incident reporting: a…
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psnet.ahrq.gov/issue/communication-failure-operating-room
February 25, 2009 - Study
Communication failure in the operating room.
Citation Text:
Halverson AL, Casey JT, Andersson J, et al. Communication failure in the operating room. Surgery. 2011;149(3):305-310. doi:10.1016/j.surg.2010.07.051.
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DOI Google Scholar PubMed BibTeX …
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psnet.ahrq.gov/issue/preventing-medical-injury
February 18, 2011 - Study
Classic
Preventing medical injury.
Citation Text:
Leape LL, Lawthers AG, Brennan TA, et al. Preventing medical injury. QRB - Qual Rev Bull. 1993;19(5):144-149. doi:10.1016/s0097-5990(16)30608-x.
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DOI Google Scholar BibTeX…
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psnet.ahrq.gov/issue/effect-work-hours-adverse-events-and-errors-health-care
August 20, 2014 - Study
The effect of work hours on adverse events and errors in health care.
Citation Text:
Olds DM, Clarke S. The effect of work hours on adverse events and errors in health care. J Safety Res. 2010;41(2):153-62. doi:10.1016/j.jsr.2010.02.002.
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Format:
DOI Go…
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psnet.ahrq.gov/issue/handoff-strategies-settings-high-consequences-failure-lessons-health-care-operations
March 14, 2018 - Study
Classic
Handoff strategies in settings with high consequences for failure: lessons for health care operations.
Citation Text:
Patterson ES. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual …