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psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
August 01, 2009 - These individuals have intimate knowledge of systems' weak points, motivation to improve reliability, … communicating the deficiencies to the manufacturing representative and suggesting changes to improve reliability
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psnet.ahrq.gov/web-mm/not-so-therapeutic-tap
December 01, 2014 - deliberate practice over time.( 17 ) Expertise, instead of experience, is a more useful predictor of high reliability
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psnet.ahrq.gov/node/49657/psn-pdf
July 01, 2012 - deliberate practice over time.(17) Expertise, instead of
experience, is a more useful predictor of high reliability
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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - handoffs, including new events of the day and anticipatory guidance, is a recommendation from other high-reliability
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psnet.ahrq.gov/node/33671/psn-pdf
July 01, 2008 - The Soil, Not the Seed: The Real Problem with Root
Cause Analysis
July 1, 2008
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
Perspective
Throughout most of his life, …
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psnet.ahrq.gov/node/837784/psn-pdf
August 05, 2022 - In Conversation With... Francoise Marvel, MD
August 5, 2022
In Conversation With.. Francoise Marvel, MD. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-francoise-marvel-md
Editor’s note: Francoise A. Marvel, MD, is an assistant professor of medicine within the Division of
Cardiology at Joh…
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psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
September 29, 2021 - SPOTLIGHT CASE
Intraosseous Line Extravasation in a Pediatric Trauma Patient
Citation Text:
Yoon J, Barnes DK. Intraosseous Line Extravasation in a Pediatric Trauma Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
May 16, 2022 - Testing of the adapted instrument shows validity and reliability similar to existing SOPS instruments … Interview
In Conversation with Timothy Vogus about High Reliability … Patient Safety
February 26, 2025
Perspective
High Reliability
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psnet.ahrq.gov/node/865455/psn-pdf
March 27, 2024 - Communication During Transitions of Care
March 27, 2024
Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/communication-during-transitions-care
Introduction
Inaccurate or untimely communication and ineffective teamwork in healthca…
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psnet.ahrq.gov/node/33680/psn-pdf
March 22, 2009 - In Conversation with...Dean Schillinger, MD
March 22, 2009
In Conversation with..Dean Schillinger, MD. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md
Editor's note: Dean Schillinger, MD, is a Professor of Medicine at University of California, San Francisco,
Directo…
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psnet.ahrq.gov/node/50611/psn-pdf
October 30, 2019 - The Lost Start Date: an Unknown Risk of E-prescribing
October 30, 2019
Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
Case Objectives
List the most common errors associated with computerized…
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration
April 11, 2024
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
The Case
An 82-year-old woman presented to the Emergency Department (ED) for …
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psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
October 30, 2019 - View More
Related Resources
Perspective
High Reliability
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psnet.ahrq.gov/perspective/emergence-application-based-healthcare
August 05, 2022 - Emergence of Application-based Healthcare
August 5, 2022
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Marvel FA, Dowell P, Mossburg SE. Emergence of Application-based Healthcare. PSNet [internet]. Rockville (MD): Agency fo…
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psnet.ahrq.gov/perspective/conversation-francoise-marvel-md
August 05, 2022 - In Conversation With... Francoise Marvel, MD
August 5, 2022
Also Read the Essay
Citation Text:
In Conversation With.. Francoise Marvel, MD. PSNet [internet]. 2022.In Conversation With... Francoise Marvel, MD. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/node/33574/psn-pdf
March 15, 2025 - Ambulatory Care Safety
March 15, 2025
Ambulatory Care Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/ambulatory-care-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Las…
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psnet.ahrq.gov/node/33571/psn-pdf
March 15, 2025 - Reporting Patient Safety Events
March 15, 2025
Reporting Patient Safety Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/reporting-patient-safety-events
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in th…
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psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph
September 01, 2008 - through improved ergonomics in the health care setting, but those strategies can only go so far when the reliability … To really get to a very high reliability state, you may need a more precise type of technology that can
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psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
September 01, 2008 - through improved ergonomics in the health care setting, but those strategies can only go so far when the reliability … To really get to a very high reliability state, you may need a more precise type of technology that can
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psnet.ahrq.gov/perspective/becoming-patient-safety-organization
July 01, 2011 - Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. … I think the reliability of the information and not exaggerating what we have is essential to our credibility