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psnet.ahrq.gov/node/45519/psn-pdf
November 01, 2017 - Morbidity and mortality conferences: a narrative review of
strategies to prioritize quality improvement.
November 1, 2017
Giesbrecht V, Au S. Morbidity and Mortality Conferences: A Narrative Review of Strategies to Prioritize
Quality Improvement. Jt Comm J Qual Patient Saf. 2016;42(11):516-527. doi:10.1016/S1553-
…
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psnet.ahrq.gov/node/836998/psn-pdf
April 27, 2022 - How will state medical boards handle cases involving
disclosure and apology for medical errors?
April 27, 2022
Wojcieszak D. How will state medical boards handle cases involving disclosure and apology for medical
errors? J Patient Saf Risk Manag. 2022;27(1):15-20. doi:10.1177/25160435211070096.
https://psnet.ahrq.…
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psnet.ahrq.gov/issue/sorry-works
November 15, 2024 - Multi-use Website
Sorry Works!
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March 17, 2011
Sorry Works! supports a full-disclosure approach to medical errors. They encourage…
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psnet.ahrq.gov/node/37051/psn-pdf
February 24, 2011 - Clinical oversight: conceptualizing the relationship
between supervision and safety.
February 24, 2011
Kennedy TJT, Lingard LA, Baker R, et al. Clinical oversight: conceptualizing the relationship between
supervision and safety. J Gen Intern Med. 2007;22(8):1080-5.
https://psnet.ahrq.gov/issue/clinical-oversight-c…
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psnet.ahrq.gov/node/60881/psn-pdf
September 02, 2020 - Advancing Patient Safety: Reviews From the Agency for
Healthcare Research and Quality's Making Healthcare
Safer III Report.
September 2, 2020
Advancing Patient Safety: Reviews From the Agency for Healthcare Research and Quality’s Making
Healthcare Safer III Report. J Patient Saf. 2020;16(3S Suppl 1):s1-s56.
doi:1…
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psnet.ahrq.gov/node/73220/psn-pdf
May 05, 2021 - Identifying barriers to and opportunities for telehealth
implementation amidst the COVID-19 pandemic by using
a human factors approach: a leap into the future of health
care delivery?
May 5, 2021
Zhang T, Mosier J, Subbian V. Identifying barriers to and opportunities for telehealth implementation amidst
the COVID…
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psnet.ahrq.gov/node/844038/psn-pdf
January 01, 2024 - The effectiveness of tele-triage during the COVID-19
pandemic: a systematic review and narrative synthesis.
February 8, 2023
Farzandipour M, Nabovati E, Sharif R. The effectiveness of tele-triage during the COVID-19 pandemic: a
systematic review and narrative synthesis. J Telemed Telecare. 2024;30(9):1367-1375.
do…
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psnet.ahrq.gov/node/44616/psn-pdf
November 04, 2015 - Development of "SWARM" as a model for high reliability,
rapid problem solving, and institutional learning.
November 4, 2015
Williams EA, Nikolai DA, Ladwig L, et al. Development of "SWARM" as a Model for High Reliability, Rapid
Problem Solving, and Institutional Learning. Jt Comm J Qual Patient Saf. 2015;41(11):508…
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psnet.ahrq.gov/node/45813/psn-pdf
January 18, 2017 - Considering chance in quality and safety performance
measures: an analysis of performance reports by boards
in English NHS trusts.
January 18, 2017
Anhøj J, Hellesøe A-MB. The problem with red, amber, green: the need to avoid distraction by random
variation in organisational performance measures. BMJ Qual Saf. 201…
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psnet.ahrq.gov/node/836760/psn-pdf
March 16, 2022 - Comprehensive Healthcare Inspection Summary Report:
Evaluation of Mental Health in Veterans Health
Administration Facilities, Fiscal Year 2020.
March 16, 2022
Washington, DC: VA Office of the Inspector General; February 17, 2022. Report No. 21-01506-76.
https://psnet.ahrq.gov/issue/comprehensive-healthcare-i…
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psnet.ahrq.gov/node/45706/psn-pdf
September 01, 2018 - Improving communication and resolution following
adverse events using a patient-created simulation
exercise.
September 1, 2018
Gallagher TH, Etchegaray J, Bergstedt B, et al. Improving Communication and Resolution Following
Adverse Events Using a Patient-Created Simulation Exercise. Health Serv Res. 2016;51 Suppl …
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psnet.ahrq.gov/node/73661/psn-pdf
September 01, 2021 - Evidence of respiratory infection transmission within
physician offices could inform outpatient infection
control.
September 1, 2021
Neprash HT, Sheridan B, Jena AB, et al. Evidence of respiratory infection transmission within physician
offices could inform outpatient infection control. Health Aff (Millwood). 2021…
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psnet.ahrq.gov/node/48063/psn-pdf
June 26, 2019 - Diagnostic accuracy of physician-staffed emergency
medical teams: a retrospective observational cohort
study of prehospital versus hospital diagnosis in a 10-
year interval.
June 26, 2019
Schewe J-C, Kappler J, Dovermann K, et al. Diagnostic accuracy of physician-staffed emergency medical
teams: a retrospective o…
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psnet.ahrq.gov/node/836722/psn-pdf
March 09, 2022 - Key use cases for artificial intelligence to reduce the
frequency of adverse drug events: a scoping review.
March 9, 2022
Syrowatka A, Song W, Amato MG, et al. Key use cases for artificial intelligence to reduce the frequency of
adverse drug events: a scoping review. Lancet Digit Health. 2022;4(2):e137-e148. doi:10…
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psnet.ahrq.gov/node/44864/psn-pdf
March 23, 2016 - Caught in the middle: a resident perspective on
influences from the learning environment that perpetuate
mistreatment.
March 23, 2016
Bynum WE, Lindeman B. Caught in the Middle: A Resident Perspective on Influences From the Learning
Environment That Perpetuate Mistreatment. Acad Med. 2016;91(3):301-4.
doi:10.1097…
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psnet.ahrq.gov/node/45683/psn-pdf
January 23, 2017 - Consensus bundle on prevention of surgical site
infections after major gynecologic surgery.
January 23, 2017
Pellegrini JE, Toledo P, Soper DE, et al. Consensus Bundle on Prevention of Surgical Site Infections After
Major Gynecologic Surgery. Obstet Gynecol. 2017;129(1):50-61. doi:10.1097/AOG.0000000000001751.
htt…
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psnet.ahrq.gov/node/854247/psn-pdf
October 04, 2023 - Cognitive biases regarding utilization of Emergency
Severity Index among emergency nurses.
October 4, 2023
Essa CD, Victor G, Khan SF, et al. Cognitive biases regarding utilization of emergency severity index
among emergency nurses. Am J Emerg Med. 2023;73:63-68. doi:10.1016/j.ajem.2023.08.021.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/840145/psn-pdf
November 16, 2022 - Failure of crisis leadership in a global pandemic: some
reflections on COVID-19 and future recommendations.
November 16, 2022
Okoli J, Arroteia NP, Ogunsade AI. Failure of crisis leadership in a global pandemic: some reflections on
COVID-19 and future recommendations. Leadersh Health Serv (Bradf Engl). 2023;36(2):1…
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psnet.ahrq.gov/node/44713/psn-pdf
January 20, 2016 - Are surgeons and anesthesiologists lying to each other or
gaming the system? A national random sample survey
about "truth-telling practices" in the perioperative setting
in the United States.
January 20, 2016
Nurok M, Lee Y-Y, Ma Y, et al. Are surgeons and anesthesiologists lying to each other or gaming the
syste…
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psnet.ahrq.gov/node/35577/psn-pdf
April 06, 2011 - Safety culture assessment in community pharmacy:
development, face validity, and feasibility of the
Manchester Patient Safety Assessment Framework.
April 6, 2011
Ashcroft DM, Morecroft C, Parker D, et al. Safety culture assessment in community pharmacy:
development, face validity, and feasibility of the Manchester…