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psnet.ahrq.gov/node/33972/psn-pdf
June 14, 2011 - Maximize Patient Safety with Advanced Root Cause
Analysis.
June 14, 2011
Corbett C, Clapper C, Johnson KM, et al. Middleton, MA: HCPro; 2004. ISBN: 1578393485
https://psnet.ahrq.gov/issue/maximize-patient-safety-advanced-root-cause-analysis
A "how-to" book for organizations that have already implemented a root cau…
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psnet.ahrq.gov/node/60011/psn-pdf
March 04, 2020 - UCSD, doc who overdosed in hospital bathroom face
lawsuits.
March 4, 2020
Clark C. MedPage Today. February 10, 2020.
https://psnet.ahrq.gov/issue/ucsd-doc-who-overdosed-hospital-bathroom-face-lawsuits
It is an institutional responsibility to monitor physicians exhibiting performance issues that put pati…
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psnet.ahrq.gov/node/37502/psn-pdf
January 30, 2008 - Nursing management of medication errors.
January 30, 2008
Luk LA, Ng WIM, Ko KKS, et al. Nursing management of medication errors. Nurs Ethics. 2008;15(1):28-39.
https://psnet.ahrq.gov/issue/nursing-management-medication-errors
This qualitative study conducted in-depth interviews with seven nurses involved in medica…
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psnet.ahrq.gov/node/37600/psn-pdf
March 19, 2008 - Medical emergency team: a review of the literature.
March 19, 2008
Barbetti J, Lee G. Medical emergency team: a review of the literature. Nurs Crit Care. 2008;13(2):80-85.
doi:10.1111/j.1478-5153.2007.00258.x.
https://psnet.ahrq.gov/issue/medical-emergency-team-review-literature
This review examines the literature…
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psnet.ahrq.gov/node/39327/psn-pdf
February 08, 2011 - Whack-a-Mole: The Price We Pay For Expecting
Perfection.
February 8, 2011
Marx D. Plano, TX: By Your Side Studios; 2009. ISBN: 9780615283074.
https://psnet.ahrq.gov/issue/whack-mole-price-we-pay-expecting-perfection
This book explores the concepts of error, system design, and behavioral choice in relation t…
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psnet.ahrq.gov/node/39575/psn-pdf
August 05, 2010 - Medical error, malpractice and complications: a moral
geography.
August 5, 2010
Zientek DM. Medical error, malpractice and complications: a moral geography. HEC Forum.
2010;22(2):145-57. doi:10.1007/s10730-010-9130-9.
https://psnet.ahrq.gov/issue/medical-error-malpractice-and-complications-moral-geography
In the …
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psnet.ahrq.gov/node/38146/psn-pdf
March 04, 2011 - Advancing measurement of patient safety culture.
March 4, 2011
Ginsburg LR, Gilin D, Tregunno D, et al. Advancing measurement of patient safety culture. Health Serv
Res. 2009;44(1):205-24. doi:10.1111/j.1475-6773.2008.00908.x.
https://psnet.ahrq.gov/issue/advancing-measurement-patient-safety-culture
Analysis of re…
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psnet.ahrq.gov/node/36363/psn-pdf
October 10, 2019 - Condition Help.
October 10, 2019
Pittsburg, PA: UPMC Shadyside Hospital: 2019.
https://psnet.ahrq.gov/issue/condition-help
This brochure informs patients and their families about the Condition H helpline at University of Pittsburgh
Medical Center (UPMC) Shadyside hospital, which can be used to call a rapid respons…
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psnet.ahrq.gov/node/73617/psn-pdf
August 26, 2021 - Recognizing Unsafe Care: What It Is and How to Report It.
August 18, 2021
Patient Safety Foundation. August 26, 2021.
https://psnet.ahrq.gov/issue/recognizing-unsafe-care-what-it-and-how-report-it
This webinar introduced medical error and harm as related concepts to identify unsafe care and enhance
response, engag…
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digital.ahrq.gov/ahrq-funded-projects/e-coaching-interactive-voice-response-ivr-enhanced-care-transition-support-2
January 01, 2023 - Living with an aging parent: "It was a beautiful invitation".
Citation
Ritchie CS, Roth DL, et al. Living with an aging parent: "It was a beautiful invitation." JAMA 2011; 306(7): 746-53.
Link
Ritchie CS, Roth DL, et al. Living with an aging parent: "It was a beautif…
Prin…
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www.ahrq.gov/nursing-home/resources/considerations-antigen-tests.html
June 01, 2022 - Considerations for Interpreting Antigen Tests in Nursing Homes
Resource: Considerations for Interpreting Antigen Tests in Nursing Homes
This document guides the interpretation of results when antigen tests are used in the following circumstances: testing of symptomatic residents and healthcare professionals…
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www.ahrq.gov/nursing-home/resources/covid-19-considerations.html
May 01, 2022 - COVID-19 Considerations for Long-Term Care Facilities
Resource: COVID-19 Considerations for Long-Term Care Facilities
This toolkit is a compilation of considerations for long-term care facilities based on lessons learned during the early months of the COVID-19 pandemic accompanied by resources to inform pl…
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www.ahrq.gov/nursing-home/resources/samhsa-disaster-distress-helpline.html
June 01, 2022 - Substance Abuse and Mental Health Services Administration (SAMHSA) Disaster Distress Helpline
Resource: Substance Abuse and Mental Health Services Administration (SAMHSA) Disaster Distress Helpline
The Substance Abuse and Mental Health Services Administration's (SAMHSA) Disaster Distress Helpline provides 2…
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www.ahrq.gov/nursing-home/resources/responding-coronavirus.html
May 01, 2022 - Responding to Coronavirus (COVID-19) in Nursing Homes
Resource: Responding to Coronavirus (COVID-19) in Nursing Homes
This guidance is intended to assist nursing homes and public health authorities with response and cohorting decisions in nursing homes. This guidance supplements but does not replace recom…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/3-are-you-ready/cahps-ambulatory-care-guide-section-3.pdf
May 01, 2017 - Organizing teams responsible for improving patient experience.
C. … larger organizations, effective performance improvement teams typically include:
o A senior leader responsible
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digital.ahrq.gov/sites/default/files/docs/citation/r18hs022701-ornstein-final-report-2014.pdf
January 01, 2014 - Learning from Primary Care Meaningful Use Exemplars - Final Report
Title of Project: Learning from Primary Care Meaningful Use Exemplars
Principal Investigator: Steven M. Ornstein, MD
Team Members: Ruth Jenkins, PhD; Cara Litvin, MD; Lynne N…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/ptsd-adults-trauma-interventions_research-protocol.pdf
November 08, 2012 - The authors of this report are responsible for its content.
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psnet.ahrq.gov/node/42172/psn-pdf
April 17, 2013 - Patient monitoring alarms in the ICU and in the operating
room.
April 17, 2013
Schmid F, Goepfert MS, Reuter DA. Patient monitoring alarms in the ICU and in the operating room. Crit
Care. 2013;17(2):216. doi:10.1186/cc12525.
https://psnet.ahrq.gov/issue/patient-monitoring-alarms-icu-and-operating-room
Discussing …
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psnet.ahrq.gov/node/38921/psn-pdf
September 09, 2009 - Using Medical Emergency Teams to detect preventable
adverse events.
September 9, 2009
Iyengar A, Baxter A, Forster AJ. Using Medical Emergency Teams to detect preventable adverse events.
Crit Care. 2009;13(4):R126. doi:10.1186/cc7983.
https://psnet.ahrq.gov/issue/using-medical-emergency-teams-detect-preventable-ad…
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psnet.ahrq.gov/node/37002/psn-pdf
September 14, 2011 - Factors influencing nurses' decisions to raise concerns
about care quality.
September 14, 2011
Attree M. Factors influencing nurses' decisions to raise concerns about care quality. J Nurs Manag.
2007;15(4):392-402.
https://psnet.ahrq.gov/issue/factors-influencing-nurses-decisions-raise-concerns-about-care-quality
…