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psnet.ahrq.gov/issue/understanding-why-quality-initiatives-succeed-or-fail-sociotechnical-systems-perspective
March 10, 2021 - Commentary
Understanding why quality initiatives succeed or fail: a sociotechnical systems perspective.
Citation Text:
Wiegmann DA. Understanding Why Quality Initiatives Succeed or Fail: A Sociotechnical Systems Perspective. Ann Surg. 2016;263(1):9-11. doi:10.1097/SLA.0000000000001333.
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psnet.ahrq.gov/issue/perinatal-high-reliability
September 29, 2010 - Review
Perinatal high reliability.
Citation Text:
Knox E, Simpson KR. Perinatal high reliability. Am J Obstet Gynecol. 2011;204(5):373-377. doi:10.1016/j.ajog.2010.10.900.
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psnet.ahrq.gov/issue/economics-patient-safety-part-iii-long-term-care-valuing-safety-long-haul
September 28, 2022 - Book/Report
The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul.
Citation Text:
The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul. de Bienassis K, Llena-Nozal A, Klazinga N for the Organisation for Econo…
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psnet.ahrq.gov/issue/organizational-learning-framework-patient-safety
November 28, 2018 - Commentary
An organizational learning framework for patient safety.
Citation Text:
Edwards MT. An Organizational Learning Framework for Patient Safety. Am J Med Qual. 2016;32(2):148-155. doi:10.1177/1062860616632295.
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psnet.ahrq.gov/issue/vanishing-nonforensic-autopsy
February 09, 2011 - Commentary
The vanishing nonforensic autopsy.
Citation Text:
Shojania KG, Burton EC. The vanishing nonforensic autopsy. N Engl J Med. 2008;358(9):873-5. doi:10.1056/NEJMp0707996.
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psnet.ahrq.gov/issue/piece-my-mind-im-sorry
November 22, 2017 - Commentary
A piece of my mind. I'm sorry.
Citation Text:
Kahn JS. A PIECE OF MY MIND. I'm Sorry. JAMA. 2015;313(24):2427-8. doi:10.1001/jama.2014.6507.
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psnet.ahrq.gov/issue/taking-action-against-clinician-burnout-systems-approach-professional-well-being
September 12, 2018 - Book/Report
Classic
Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.
Citation Text:
Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. National Academies of Sciences, Engineering, and Me…
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psnet.ahrq.gov/issue/advancing-diagnostic-excellence-maternal-health-care-proceedings-workshop-brief
September 12, 2018 - Book/Report
Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief.
Citation Text:
Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief. National Academies of Sciences, Engineering, and Medicine. Washington, DC…
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psnet.ahrq.gov/issue/advancing-maternal-health-equity-and-reducing-maternal-mortality-workshop
May 19, 2021 - Meeting/Conference Proceedings
Advancing Maternal Health Equity and Reducing Maternal Mortality Workshop.
Citation Text:
Advancing Maternal Health Equity and Reducing Maternal Mortality Workshop. National Academies of Sciences, Engineering, and Medicine. June 7-8, 2021.
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psnet.ahrq.gov/issue/national-trauma-care-system-integrating-military-and-civilian-trauma-systems-achieve-zero
September 12, 2018 - Book/Report
A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.
Citation Text:
A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Nat…
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psnet.ahrq.gov/issue/seeing-systems-health-care-organizations
January 25, 2023 - Commentary
Seeing systems in health care organizations.
Citation Text:
Friedman LH, King JB, Bella D. Seeing systems in health care organizations. Physician Exec. 2007;33(4):20-9.
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psnet.ahrq.gov/issue/organizational-learning-hospitals-realist-review
June 19, 2019 - Review
Organizational learning in hospitals: a realist review.
Citation Text:
Lyman B, Jacobs JD, Hammond EL, et al. Organizational learning in hospitals: A realist review. J Adv Nurs. 2019;75(11):2352-2377. doi:10.1111/jan.14091.
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psnet.ahrq.gov/issue/system-governance-towards-improved-patient-safety-key-functions-approaches-and-pathways
October 07, 2020 - Book/Report
System Governance Towards Improved Patient Safety: Key Functions, Approaches and Pathways to Implementation.
Citation Text:
System Governance Towards Improved Patient Safety: Key Functions, Approaches and Pathways to Implementation. Auraaen A, Saar K, Klazinga N for the Organ…
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psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md
February 26, 2025 - And this is a resident saying this in front of a whole room full of people.
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psnet.ahrq.gov/perspective/weekend-effect-cardiology-it-real-if-so-can-it-be-fixed
June 01, 2017 - University of California, Irvine Irvine, CA
Mahdi Khoshchehreh, MD, MS Anatomic and Clinical Pathology Resident
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psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
October 26, 2022 - Diagnosing a Missed Diagnosis
Citation Text:
Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/low-totem-pole
October 01, 2003 - SPOTLIGHT CASE
Low on the Totem Pole
Citation Text:
Wachter R. Low on the Totem Pole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/perspective/patient-and-family-roles-safety
June 14, 2023 - The Adverse Effects of the COVID-19 Pandemic on Nursing Home Resident Well-Being. … ambulatory practice, and every long-term care community should have processes in place for a patient or a resident
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
June 14, 2023 - ambulatory practice, and every long-term care community should have processes in place for a patient or a resident … The Adverse Effects of the COVID-19 Pandemic on Nursing Home Resident Well-Being.
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psnet.ahrq.gov/issue/patterns-and-predictors-medication-discrepancies-primary-care
October 19, 2022 - Study
Patterns and predictors of medication discrepancies in primary care.
Citation Text:
Coletti DJ, Stephanou H, Mazzola N, et al. Patterns and predictors of medication discrepancies in primary care. J Eval Clin Pract. 2015;21(5):831-9. doi:10.1111/jep.12387.
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