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psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps
February 24, 2011 - Study
Classic
Communication failures: an insidious contributor to medical mishaps.
Citation Text:
Sutcliffe K, Lewton E, Rosenthal M. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79(2):186-194.
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psnet.ahrq.gov/web-mm/pocket-syringe-swap
July 01, 2006 - Despite the ubiquity of drug errors in anesthesia, there is little reliable evidence regarding the actual … Without reliable knowledge of the relative frequency of the different types of medication error, and
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psnet.ahrq.gov/issue/impact-high-reliability-education-adverse-event-reporting-registered-nurses
January 07, 2011 - Study
Impact of high-reliability education on adverse event reporting by registered nurses.
Citation Text:
McFarland DM, Doucette JN. Impact of High-Reliability Education on Adverse Event Reporting by Registered Nurses. J Nurs Care Qual. 2018;33(3):285-290. doi:10.1097/NCQ.00000000000002…
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psnet.ahrq.gov/curated-library/organizational-learning
April 17, 2025 - Breadcrumb
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Organizational Learning
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team…
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psnet.ahrq.gov/issue/near-misses-are-opportunity-improve-patient-safety-adapting-strategies-high-reliability
July 01, 2011 - Review
Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability organizations to healthcare.
Citation Text:
Van Spall H, Kassam A, Tollefson TT. Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability orga…
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psnet.ahrq.gov/issue/longitudinal-study-clinical-peer-reviews-impact-quality-and-safety-us-hospitals
March 29, 2023 - Study
A longitudinal study of clinical peer review's impact on quality and safety in US hospitals.
Citation Text:
Edwards MT. A longitudinal study of clinical peer review's impact on quality and safety in U.S. hospitals. J Healthc Manag. 2013;58(5):369-85.
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psnet.ahrq.gov/print/pdf/node/73848
July 01, 2022 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Maternal Safety
Curated Library
Foundations
Maternal Safety
Marla Shauer, PhD(c), MSN, CNM; Amy Nichols, EdD, RN, CNS, CHSE, ANEF; Audrey Lyndon, RN,
PhD, FAAN | January, 31 2024
Pregnancy, childbirth, and the postpartum year present a comp…
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psnet.ahrq.gov/issue/assessment-global-trigger-tool-measure-monitor-and-evaluate-patient-safety-cancer-patients
April 22, 2015 - Study
Assessment of the global trigger tool to measure, monitor and evaluate patient safety in cancer patients: reliability concerns are raised.
Citation Text:
Mattsson TO, Knudsen JL, Lauritsen J, et al. Assessment of the global trigger tool to measure, monitor and evaluate patient sa…
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psnet.ahrq.gov/issue/board-bedside-how-application-financial-structures-safety-and-quality-can-drive
January 29, 2015 - Study
From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system.
Citation Text:
Austin M, Demski R, Callender T, et al. From Board to Bedside: How the Application of Financial Structures to Safety and Q…
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psnet.ahrq.gov/issue/applying-lean-sigma-solutions-mistake-proof-chemotherapy-preparation-process
September 02, 2015 - Commentary
Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process.
Citation Text:
Aboumatar HJ, Winner L, Davis RO, et al. Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process. Jt Comm J Qual Patient Saf. 2010;36(2):79-86.
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psnet.ahrq.gov/node/33578/psn-pdf
September 15, 2024 - Human Factors Engineering
September 15, 2024
Human Factors Engineering. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/human-factors-engineering
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 safe…
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psnet.ahrq.gov/issue/cost-inpatient-falls-and-cost-benefit-analysis-implementation-evidence-based-fall-prevention
December 02, 2020 - Study
Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall prevention program.
Citation Text:
Dykes PC, Curtin-Bowen M, Lipsitz S, et al. Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall prevention prog…
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psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
December 15, 2024 - Improving Patient Safety and Team Communication through Daily Huddles
Citation Text:
Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/good-catch-operating-room
August 27, 2017 - High reliability organizations (HROs) prioritize safety, emphasizing consistent performance with reliable
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psnet.ahrq.gov/issue/lean-hospitals-improving-quality-patient-safety-and-employee-engagement-third-edition
May 04, 2016 - Book/Report
Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Third Edition.
Citation Text:
Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Third Edition. Graban M. Boca Raton, FL: Productivity Press; 2016. ISBN: 9781498743259.
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psnet.ahrq.gov/issue/structural-and-organizational-issues-patient-safety-comparison-health-care-other-high-hazard
February 09, 2011 - Commentary
Classic
Structural and organizational issues in patient safety: a comparison of health care to other high-hazard industries.
Citation Text:
Structural and organizational issues in patient safety: a comparison of health care to other high-hazard indust…
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digital.ahrq.gov/sites/default/files/docs/citation/EHR_Usability_Toolkit_Background_Report.pdf
January 26, 2006 - This requires users
perform a card-sorting technique.94,175 Although it is considered a reliable and … Many
are reliable and
validated. … To ensure a questionnaire provides high-quality
results, it should be both reliable and valid. … It is a reliable and
valid instrument that can be used as a general measure of user satisfaction with … The user action
framework: A reliable foundation for usability engineering
support tools.
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psnet.ahrq.gov/issue/use-cascading-a3s-drive-systemwide-improvement
January 29, 2015 - Commentary
Use of cascading A3s to drive systemwide improvement.
Citation Text:
Winner LE, Burroughs TJ, Cady-Reh JA, et al. Use of Cascading A3s to Drive Systemwide Improvement. Jt Comm J Qual Patient Saf. 2017;43(8):422-428. doi:10.1016/j.jcjq.2017.03.011.
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psnet.ahrq.gov/issue/improving-quality-health-care-whats-taking-so-long
April 06, 2016 - Commentary
Classic
Improving the quality of health care: what's taking so long?
Citation Text:
Chassin MR. Improving The Quality Of Health Care: What’s Taking So Long? Health Aff. 2013;32(10):1761-1765. doi:10.1377/hlthaff.2013.0809.
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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/vision-in-children-ages-6-months-to-5-years-screening
December 17, 2015 - Share to Facebook
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Final Research Plan
Vision in Children Ages 6 Months to 5 Years: Screening
December 17, 2015
Recommendations made by the USPSTF are independent of the U.S. government. They shou…