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psnet.ahrq.gov/issue/enterprise-take-patient-safety
December 21, 2009 - Newspaper/Magazine Article
The enterprise take on patient safety.
Citation Text:
Rogoski RR. The enterprise take on patient safety. Health management technology. 2005;26(8):12, 14, 16-7.
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psnet.ahrq.gov/issue/improving-usability-intravenous-medication-labels-support-safe-medication-delivery
September 26, 2016 - Study
Improving the usability of intravenous medication labels to support safe medication delivery.
Citation Text:
Bauer DT, Guerlain S. Improving the usability of intravenous medication labels to support safe medication delivery. International journal of industrial ergonomics. 2011;41…
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psnet.ahrq.gov/issue/learning-malpractice-claims-about-negligent-adverse-events-primary-care-united-states
April 07, 2011 - Study
Learning from malpractice claims about negligent, adverse events in primary care in the United States.
Citation Text:
Phillips RL, Bartholomew LA, Dovey S, et al. Learning from malpractice claims about negligent, adverse events in primary care in the United States. Qual Saf Healt…
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psnet.ahrq.gov/primer/health-care-associated-infections
December 15, 2024 - living in long-term care facilities were hit especially hard, with CMS reporting 172,753 nursing home resident
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psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
January 01, 2020 - repletion
24
Systems Change Needed (5)
• Consider the experience and competence of the primary
resident
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psnet.ahrq.gov/node/33844/psn-pdf
October 01, 2017 - Presenteeism among resident
physicians. JAMA. 2010;304:1166-1168. [go to PubMed]
13.
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psnet.ahrq.gov/print/pdf/node/866984
January 01, 2020 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Interdisciplinary teamwork
Curated Library
Foundations
Medical teamwork and the evolution of safety science: a critical review.
Neuhaus C, Lutnæs DE, Bergström J. Cogn Technol Work. 2020;22:13-27.
In this narrative review, the authors contr…
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psnet.ahrq.gov/issue/american-college-endocrinology-and-american-association-clinical-endocrinologists-position
August 20, 2018 - Commentary
American College of Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical system errors in diabetes and endocrinology.
Citation Text:
Bates DW, Clark NG, Cook RI, et al. American College of Endocrinology and Amer…
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psnet.ahrq.gov/issue/relationship-between-response-time-and-diagnostic-accuracy
February 06, 2014 - Study
The relationship between response time and diagnostic accuracy.
Citation Text:
Sherbino J, Dore KL, Wood TJ, et al. The relationship between response time and diagnostic accuracy. Acad Med. 2012;87(6):785-791. doi:10.1097/ACM.0b013e318253acbd.
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psnet.ahrq.gov/issue/safety-considerations-learning-new-procedures-survey-surgeons
January 23, 2017 - Study
Safety considerations in learning new procedures: a survey of surgeons.
Citation Text:
Jaffe TA, Hasday SJ, Knol M, et al. Safety considerations in learning new procedures: a survey of surgeons. J Surg Res. 2017;218:361-366. doi:10.1016/j.jss.2017.06.058.
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psnet.ahrq.gov/issue/economic-measurement-medical-errors-using-hospital-claims-database
March 03, 2011 - Study
Economic measurement of medical errors using a hospital claims database.
Citation Text:
David G, Gunnarsson CL, Waters HC, et al. Economic measurement of medical errors using a hospital claims database. Value Health. 2013;16(2):305-10. doi:10.1016/j.jval.2012.11.010.
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psnet.ahrq.gov/issue/cognitive-balanced-model-conceptual-scheme-diagnostic-decision-making
July 10, 2013 - Study
Cognitive balanced model: a conceptual scheme of diagnostic decision making.
Citation Text:
Lucchiari C, Pravettoni G. Cognitive balanced model: a conceptual scheme of diagnostic decision making. J Eval Clin Pract. 2012;18(1):82-8. doi:10.1111/j.1365-2753.2011.01771.x.
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psnet.ahrq.gov/issue/apology-and-unintended-harm-global-health
March 19, 2019 - Commentary
Apology and unintended harm in global health.
Citation Text:
Addiss DG, Amon JJ. Apology and Unintended Harm in Global Health. Health Hum Rights. 2019;21(1):19-32.
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psnet.ahrq.gov/issue/best-medical-care-world
December 21, 2014 - Commentary
The best medical care in the world.
Citation Text:
Reilly BM. The Best Medical Care in the World. N Engl J Med. 2018;378(18):1741-1743. doi:10.1056/NEJMms1802026.
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psnet.ahrq.gov/issue/new-tool-give-hospitalists-feedback-improve-interprofessional-teamwork-and-advance-patient
February 10, 2015 - Commentary
A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care.
Citation Text:
Chesluk BJ, Bernabeo E, Hess B, et al. A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care. Health Aff…
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psnet.ahrq.gov/issue/incorporating-metacognition-morbidity-and-mortality-rounds-next-frontier-quality-improvement
September 21, 2016 - Review
Incorporating metacognition into morbidity and mortality rounds: the next frontier in quality improvement.
Citation Text:
Katz D, Detsky AS. Incorporating metacognition into morbidity and mortality rounds: The next frontier in quality improvement. J Hosp Med. 2016;11(2):120-2. doi…
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psnet.ahrq.gov/issue/medical-errors-education-prospective-study-new-educational-tool
March 20, 2024 - Study
Medical errors education: a prospective study of a new educational tool.
Citation Text:
Paxton JH, Rubinfeld IS. Medical errors education: A prospective study of a new educational tool. Am J Med Qual. 2010;25(2):135-42. doi:10.1177/1062860609353345.
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psnet.ahrq.gov/issue/iatrogenic-events-resulting-intensive-care-admission-frequency-cause-and-disclosure-patients
September 30, 2010 - Study
Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.
Citation Text:
Lehmann LS, Puopolo AL, Shaykevich S, et al. Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patient…
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psnet.ahrq.gov/issue/enotss-platform-surgeons-nontechnical-skills-performance-improvement
July 01, 2017 - Commentary
The eNOTSS platform for surgeons’ nontechnical skills performance improvement.
Citation Text:
Pradarelli JC, Yule S, Smink DS. The eNOTSS Platform for Surgeons’ Nontechnical Skills Performance Improvement. JAMA Surg. 2020;155(5):438-439. doi:10.1001/jamasurg.2019.5880.
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psnet.ahrq.gov/issue/medical-error-identification-disclosure-and-reporting-do-emergency-medicine-provider-groups
April 11, 2011 - Study
Medical error identification, disclosure, and reporting: do emergency medicine provider groups differ?
Citation Text:
Hobgood C, Weiner B, Tamayo-Sarver JH. Medical error identification, disclosure, and reporting: do emergency medicine provider groups differ? Acad Emerg Med. 2006…