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  1. Partnering with pediatric patients and families in high reliability to identify and reduce preventable safety events. | PSNet

    psnet.ahrq.gov/issue/partnering-pediatric-patients-and-families-high-reliability-identify-and-reduce-preventable
    December 02, 2020 - Commentary Partnering with pediatric patients and families in high reliability to identify and reduce preventable safety events. Citation Text: Partnering with pediatric patients and families in high reliability to identify and reduce preventable safety events. Kirby J, Cannon C, Darrah …

  2. Disclosing medical errors to patients: effects of nonverbal involvement. | PSNet

    psnet.ahrq.gov/issue/disclosing-medical-errors-patients-effects-nonverbal-involvement
    June 14, 2017 - Study Disclosing medical errors to patients: effects of nonverbal involvement. Citation Text: Hannawa AF. Disclosing medical errors to patients: effects of nonverbal involvement. Patient Educ Couns. 2014;94(3):310-313. doi:10.1016/j.pec.2013.11.007. Copy Citation Format: DO…

  3. Resident Safety Practices in Nursing Home Settings. | PSNet

    psnet.ahrq.gov/issue/resident-safety-practices-nursing-home-settings
    July 27, 2018 - Book/Report Resident Safety Practices in Nursing Home Settings. Citation Text: Resident Safety Practices in Nursing Home Settings. Simmons S, Schnelle J, Slagle J, et al. Technical Brief No. 24. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-…

  4. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. | PSNet

    psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm
    June 21, 2016 - Book/Report RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Citation Text: RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient Safety Foundation; 2015. Copy Citation Save Save to your library Print …

  5. How communication "failed" or "saved the day": counterfactual accounts of medical errors. | PSNet

    psnet.ahrq.gov/issue/how-communication-failed-or-saved-day-counterfactual-accounts-medical-errors
    September 21, 2022 - Study How communication "failed" or "saved the day": counterfactual accounts of medical errors. Citation Text: Street RL, Petrocelli JV, Amroze A, et al. How Communication “Failed” or “Saved the Day”: Counterfactual Accounts of Medical Errors. J Patient Exp. 2020;7(6):1247-1254. doi:10.1…

  6. How policy makers can smooth the way for communication-and-resolution programs. | PSNet

    psnet.ahrq.gov/issue/how-policy-makers-can-smooth-way-communication-and-resolution-programs
    December 19, 2018 - Commentary How policy makers can smooth the way for communication-and-resolution programs. Citation Text: Sage WM, Gallagher TH, Armstrong S, et al. How policy makers can smooth the way for communication-and- resolution programs. Health Aff (Millwood). 2014;33(1):11-9. doi:10.1377/hlthaf…

  7. Building and sustaining a systemwide culture of safety. | PSNet

    psnet.ahrq.gov/issue/building-and-sustaining-systemwide-culture-safety
    July 21, 2009 - Commentary Building and sustaining a systemwide culture of safety. Citation Text: Yates GR, Bernd DL, Sayles SM, et al. Building and sustaining a systemwide culture of safety. Jt Comm J Qual Patient Saf. 2005;31(12):684-689. Copy Citation Format: Google Scholar PubMed Bib…

  8. Action Planning Tool for the AHRQ Surveys on Patient Safety Culture. | PSNet

    psnet.ahrq.gov/issue/action-planning-tool-ahrq-surveys-patient-safety-culture
    February 12, 2019 - Toolkit Action Planning Tool for the AHRQ Surveys on Patient Safety Culture. Citation Text: Action Planning Tool for the AHRQ Surveys on Patient Safety Culture. Yount N, Edelman S, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; November 2022. AHRQ Publication …

  9. IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events. | PSNet

    psnet.ahrq.gov/issue/ihi-skilled-nursing-facility-trigger-tool-measuring-adverse-events
    February 15, 2017 - Book/Report IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events. Citation Text: IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events. Adler L, Moore J, Federico F. Cambridge, MA: Institute for Healthcare Improvement; November 2015. Copy Citation …

  10. Critical conversations: a call for a nonprocedural "time out." | PSNet

    psnet.ahrq.gov/issue/critical-conversations-call-nonprocedural-time-out
    February 18, 2011 - Commentary Critical conversations: a call for a nonprocedural "time out." Citation Text: Sehgal NL, Fox M, Sharpe B, et al. Critical conversations: a call for a nonprocedural "time out". J Hosp Med. 2011;6(4):225-30. doi:10.1002/jhm.853. Copy Citation Format: DOI Google Sch…

  11. Deprescribing as a clinical improvement focus. | PSNet

    psnet.ahrq.gov/issue/deprescribing-clinical-improvement-focus
    April 08, 2011 - Study Deprescribing as a clinical improvement focus. Citation Text: Dharmarajan TS, Choi H, Hossain N, et al. Deprescribing as a Clinical Improvement Focus. J Am Med Dir Assoc. 2020;21(3):355-360. doi:10.1016/j.jamda.2019.08.031. Copy Citation Format: DOI Google Scholar Pub…

  12. Nursing 2006 Patient-safety survey report. | PSNet

    psnet.ahrq.gov/issue/nursing-2006-patient-safety-survey-report
    March 01, 2023 - Study Nursing 2006 Patient-safety survey report. Citation Text: Manno M, Hogan P, Heberlein V, et al. Nursing 2006. Patient-safety survey report. Nursing (Brux). 2006;36(5):54-64. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…

  13. Impact of high-reliability education on adverse event reporting by registered nurses. | PSNet

    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…

  14. The problem with medication reconciliation. | PSNet

    psnet.ahrq.gov/issue/problem-medication-reconciliation
    May 08, 2017 - Commentary The problem with medication reconciliation. Citation Text: Pevnick JM, Shane R, Schnipper JL. The problem with medication reconciliation. BMJ Qual Saf. 2016;25(9):726-730. doi:10.1136/bmjqs-2015-004734. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNo…

  15. Narrativizing nursing students' experiences with medical errors during clinicals. | PSNet

    psnet.ahrq.gov/issue/narrativizing-nursing-students-experiences-medical-errors-during-clinicals
    September 28, 2010 - Study Narrativizing nursing students' experiences with medical errors during clinicals. Citation Text: Noland CM, Carmack HJ. Narrativizing Nursing Students' Experiences With Medical Errors During Clinicals. Qual Health Res. 2015;25(10):1423-34. doi:10.1177/1049732314562892. Copy Citat…

  16. Coaching the debriefer: peer coaching to improve debriefing quality in simulation programs. | PSNet

    psnet.ahrq.gov/issue/coaching-debriefer-peer-coaching-improve-debriefing-quality-simulation-programs
    July 31, 2019 - Commentary Coaching the debriefer: peer coaching to improve debriefing quality in simulation programs. Citation Text: Cheng A, Grant V, Huffman J, et al. Coaching the Debriefer: Peer Coaching to Improve Debriefing Quality in Simulation Programs. Simul Healthc. 2017;12(5):319-325. doi:10.…

  17. Communicating medication changes to community pharmacy post-discharge: the good, the bad, and the improvements. | PSNet

    psnet.ahrq.gov/issue/communicating-medication-changes-community-pharmacy-post-discharge-good-bad-and-improvements
    June 11, 2014 - Study Communicating medication changes to community pharmacy post-discharge: the good, the bad, and the improvements. Citation Text: Urban R, Paloumpi E, Rana N, et al. Communicating medication changes to community pharmacy post-discharge: the good, the bad, and the improvements. Int J…

  18. Enhancing the effectiveness of team debriefings in medical simulation: more best practices. | PSNet

    psnet.ahrq.gov/issue/enhancing-effectiveness-team-debriefings-medical-simulation-more-best-practices
    March 17, 2021 - Commentary Enhancing the effectiveness of team debriefings in medical simulation: more best practices. Citation Text: Lyons R, Lazzara EH, Benishek LE, et al. Enhancing the effectiveness of team debriefings in medical simulation: more best practices. Jt Comm J Qual Patient Saf. 2015;41(3…

  19. Improving patient care. The cognitive psychology of missed diagnoses. | PSNet

    psnet.ahrq.gov/issue/improving-patient-care-cognitive-psychology-missed-diagnoses
    October 03, 2012 - Commentary Improving patient care. The cognitive psychology of missed diagnoses. Citation Text: Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005;142(2):115-120. Copy Citation Format: Google Scholar PubMed BibTeX End…

  20. Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. | PSNet

    psnet.ahrq.gov/issue/prevention-3-never-events-operating-room-fires-gossypiboma-and-wrong-site-surgery
    February 10, 2012 - Review Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. Citation Text: Zahiri HR, Stromberg J, Skupsky H, et al. Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. Surg Innov. 2011;18(1):55-…
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