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psnet.ahrq.gov/issue/second-opinions-improve-healthcare-outcomes-and-reduce-costs
April 12, 2023 - Newspaper/Magazine Article
Second opinions improve healthcare outcomes and reduce costs.
Citation Text:
Hébert AR. Second opinions improve healthcare outcomes and reduce costs. Employee Benefit News. 2020;June 8.
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psnet.ahrq.gov/issue/taking-risky-business-out-mri-suite
September 12, 2016 - Newspaper/Magazine Article
Taking risky business out of the MRI suite.
Citation Text:
Rozovsky FA, Gilk TB, Latina RJ. Managing liability exposure and safety. Taking risky business out of the MRI suite. Materials management in health care. 2006;15(1):18-23.
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psnet.ahrq.gov/issue/measuring-safety-climate-health-care
March 01, 2023 - Review
Measuring safety climate in health care.
Citation Text:
Flin R, Burns C, Mearns K, et al. Measuring safety climate in health care. Qual Saf Health Care. 2006;15(2):109-15.
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psnet.ahrq.gov/issue/reducing-adverse-drug-events
August 09, 2017 - Book/Report
Classic
Reducing Adverse Drug Events.
Citation Text:
Reducing Adverse Drug Events. Leape LL, Kabcenell A, Berwick DM et al. Boston, MA: Institute for Healthcare Improvement; 1998.
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psnet.ahrq.gov/issue/common-body-care-ethics-and-politics-teamwork-operating-theater-are-inseparable
September 27, 2016 - Commentary
A common body of care: the ethics and politics of teamwork in the operating theater are inseparable.
Citation Text:
Bleakley A. A common body of care: the ethics and politics of teamwork in the operating theater are inseparable. J Med Philos. 2006;31(3):305-22.
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psnet.ahrq.gov/issue/fixing-broken-bones-and-broken-homes-domestic-violence-patient-safety-issue
September 03, 2011 - Study
Fixing broken bones and broken homes: domestic violence as a patient safety issue.
Citation Text:
Cohn F, Rudman WJ. Fixing broken bones and broken homes: domestic violence as a patient safety issue. Jt Comm J Qual Saf. 2004;30(11):636-646.
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psnet.ahrq.gov/issue/communication-failure-basic-components-contributing-factors-and-call-structure
March 04, 2011 - Commentary
Communication failure: basic components, contributing factors, and the call for structure.
Citation Text:
Dayton E, Henriksen K. Communication failure: basic components, contributing factors, and the call for structure. Jt Comm J Qual Patient Saf. 2007;33(1):34-47.
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psnet.ahrq.gov/issue/apologies-and-medical-error
November 16, 2022 - Commentary
Apologies and medical error.
Citation Text:
Robbennolt JK. Apologies and medical error. Clin Orthop Relat Res. 2009;467(2):376-82. doi:10.1007/s11999-008-0580-1.
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psnet.ahrq.gov/issue/negligence-genuine-error-and-litigation
July 10, 2024 - Review
Negligence, genuine error, and litigation.
Citation Text:
Sohn D. Negligence, genuine error, and litigation. Int J Gen Med. 2013. doi:10.2147/ijgm.s24256.
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psnet.ahrq.gov/issue/preventing-vincristine-administration-errors-does-evidence-support-minibag-infusions
January 01, 2008 - Commentary
Preventing vincristine administration errors: does evidence support minibag infusions?
Citation Text:
Mahon SM, Schulmeister L. Preventing Vincristine Administration Errors: Does Evidence Support Minibag Infusions? Clin J Oncol Nurs. 2006;10(2). doi:10.1188/06.cjon.271-273. …
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psnet.ahrq.gov/issue/pharmacist-involvement-rapid-response-team-community-hospital
August 08, 2018 - Commentary
Pharmacist involvement in a rapid-response team at a community hospital.
Citation Text:
Cooper BE. Pharmacist involvement in a rapid-response team at a community hospital. Am J Health Syst Pharm. 2007;64(7):694, 697-8.
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psnet.ahrq.gov/issue/improving-patient-care-my-right-knee
August 04, 2021 - Commentary
Improving patient care. My right knee.
Citation Text:
Berwick DM. Improving patient care. My right knee. Ann Intern Med. 2005;142(2):121-5.
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psnet.ahrq.gov/issue/does-simulation-improve-patient-safety-self-efficacy-competence-operational-performance-and
May 25, 2016 - Commentary
Does simulation improve patient safety?: self-efficacy, competence, operational performance, and patient safety.
Citation Text:
Nishisaki A, Keren R, Nadkarni V. Does simulation improve patient safety? Self-efficacy, competence, operational performance, and patient safety. A…
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psnet.ahrq.gov/issue/confusion-about-epinephrine-dosing-leading-iatrogenic-overdose-life-threatening-problem
August 04, 2021 - Commentary
Confusion about epinephrine dosing leading to iatrogenic overdose: a life-threatening problem with a potential solution.
Citation Text:
Kanwar M, Irvin CB, Frank JJ, et al. Confusion about epinephrine dosing leading to iatrogenic overdose: a life-threatening problem with a p…
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effectivehealthcare.ahrq.gov/sites/default/files/eaagleston.pdf
October 08, 2025 - be suitable for the app format, you know, and it should represent,
you know, your expertise, your skill
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www.ahrq.gov/hai/tools/surgery/modules/implementation/opt-briefings-fac-notes.html
December 01, 2017 - Take the opportunity to introduce each team member, explain skill competencies, and assign tasks. … of providers on the white board; this will reinforce team members’ ability to recall names, assess skill
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module2-team-structure.pptx
January 12, 2022 - Core Teams should be large enough to include skill overlap between members to allow workload sharing
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module2-presenters-notes.pdf
January 12, 2022 - Core Teams should be large enough to include skill overlap between members to
allow workload sharing
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www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-slides.html
December 01, 2017 - implementation, the attributes of the practice environment should be examined and managed as well as the skill
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psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
June 01, 2016 - Third, patients are transferred from experienced trainees to those with much less experience and skill