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psnet.ahrq.gov/node/43022/psn-pdf
May 29, 2014 - Using simulation to improve root cause analysis of
adverse surgical outcomes.
May 29, 2014
Slakey DP, Simms ER, Rennie K, et al. Using simulation to improve root cause analysis of adverse surgical
outcomes. Int J Qual Health Care. 2014;26(2):144-50. doi:10.1093/intqhc/mzu011.
https://psnet.ahrq.gov/issue/using-sim…
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psnet.ahrq.gov/node/36917/psn-pdf
September 01, 2011 - Analysis of deaths related to anesthesia in the period
1996-2004 from closed claims registered by the Danish
Patient Insurance Association.
September 1, 2011
Hove LD, Steinmetz J, Christoffersen JK, et al. Analysis of deaths related to anesthesia in the period 1996-
2004 from closed claims registered by the Danish…
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psnet.ahrq.gov/node/74108/psn-pdf
January 01, 2022 - 'It depends': The complexity of allowing residents to fail
from the perspective of clinical supervisors.
November 24, 2021
Klasen JM, Teunissen PW, Driessen EW, et al. ‘It depends’: the complexity of allowing residents to fail from
the perspective of clinical supervisors. Med Teach. 2022;44(2):196-205.
doi:10.1080…
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psnet.ahrq.gov/node/42860/psn-pdf
March 20, 2014 - Eight critical factors in creating and implementing a
successful simulation program.
March 20, 2014
Lazzara EH, Benishek LE, Dietz AS, et al. Eight critical factors in creating and implementing a successful
simulation program. Jt Comm J Qual Patient Saf. 2014;40(1):21-29.
https://psnet.ahrq.gov/issue/eight-critica…
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psnet.ahrq.gov/node/43515/psn-pdf
July 03, 2016 - Targeting improvements in patient safety at a large
academic center: an institutional handoff curriculum for
graduate medical education.
July 3, 2016
Allen S, Caton C, Cluver J, et al. Targeting improvements in patient safety at a large academic center: an
institutional handoff curriculum for graduate medical educ…
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psnet.ahrq.gov/node/34750/psn-pdf
May 21, 2019 - The Basics of FMEA. 2nd ed.
May 21, 2019
McDermott RE, Mikulak RJ, Beauregard MR. New York, NY: CRC Press; 2009. ISBN: 9781563273773.
https://psnet.ahrq.gov/issue/basics-fmea-2nd-edition
The authors provide a handbook that serves as the core tool for understanding and implementing the
failure mode and effect analy…
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psnet.ahrq.gov/node/43019/psn-pdf
March 05, 2014 - Augmenting health care failure modes and effects
analysis with simulation.
March 5, 2014
Nielsen DS, Dieckmann P, Mohr M, et al. Augmenting health care failure modes and effects analysis with
simulation. Simul Healthc. 2014;9(1):48-55. doi:10.1097/SIH.0b013e3182a3defd.
https://psnet.ahrq.gov/issue/augmenting-healt…
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psnet.ahrq.gov/node/44469/psn-pdf
September 16, 2015 - Unexpected Death of a Patient During Treatment With
Multiple Medications, Tomah VA Medical Center, Tomah,
Wisconsin.
September 16, 2015
Washington, DC: VA Office of Inspector General. August 6, 2015. Report No. 15-02131-471.
https://psnet.ahrq.gov/issue/unexpected-death-patient-during-treatment-multiple-medication…
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psnet.ahrq.gov/node/46963/psn-pdf
April 18, 2018 - A Just Culture Guide.
April 18, 2018
NHS Improvement. London, UK: National Health Service; March 15, 2018.
https://psnet.ahrq.gov/issue/just-culture-guide
Although focusing on system failure has been highlighted as key to improving patient safety, individual
behaviors must also be recognized as contributors to ris…
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psnet.ahrq.gov/node/41802/psn-pdf
October 31, 2012 - Relationship between high-fidelity simulation and patient
safety in prelicensure nursing education: a
comprehensive review.
October 31, 2012
Blum CA, Parcells DA. Relationship between high-fidelity simulation and patient safety in prelicensure
nursing education: a comprehensive review. J Nurs Educ. 2012;51(8):429-…
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psnet.ahrq.gov/node/39603/psn-pdf
February 16, 2011 - The Schwartz Center Rounds: evaluation of an
interdisciplinary approach to enhancing patient-centered
communication, teamwork, and provider support.
February 16, 2011
Lown BA, Manning CF. The Schwartz Center Rounds: evaluation of an interdisciplinary approach to
enhancing patient-centered communication, teamwork, …
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/index.html
September 01, 2021 - Long-term Care Facilities
Resources for long-term care facilities
Improving Patient Safety in Long-Term Care Facilities
Detecting and promptly reporting changes in a nursing home resident's condition are critical for ensuring the resident's well-being and safety. Such changes may represent a patient s…
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digital.ahrq.gov/organization/michigan-state-university
January 01, 2023 - Michigan State University
Telehealth Post-Pandemic: A Roadmap for the Coming Decade
Description
This conference grant will support a multidisciplinary Think Tank to develop and disseminate telehealth best practices, training curriculum recommendations, and policy recommendatio…
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digital.ahrq.gov/location/usa-mi-east-lansing
January 01, 2023 - USA, MI, East Lansing
Telehealth Post-Pandemic: A Roadmap for the Coming Decade
Description
This conference grant will support a multidisciplinary Think Tank to develop and disseminate telehealth best practices, training curriculum recommendations, and policy recommendations t…
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psnet.ahrq.gov/node/73496/psn-pdf
July 14, 2021 - Racism in pain medicine: we can and should do more.
July 14, 2021
Strand NH, Mariano ER, Goree JH, et al. Racism in pain medicine: we can and should do more. Mayo Clin
Proc. 2021;96(6):1394-1400. doi:10.1016/j.mayocp.2021.02.030.
https://psnet.ahrq.gov/issue/racism-pain-medicine-we-can-and-should-do-more
Systemic …
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psnet.ahrq.gov/node/850938/psn-pdf
June 21, 2023 - AI in medicine needs to be carefully deployed to counter
bias – and not entrench it.
June 21, 2023
Levi R, Gorenstein D. Health Shots. National Public Radio. June 6, 2023.
https://psnet.ahrq.gov/issue/ai-medicine-needs-be-carefully-deployed-counter-bias-and-not-entrench-it
Systemic biases are present in data …
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psnet.ahrq.gov/node/72796/psn-pdf
March 03, 2021 - Patient safety. Factors for and perceived consequences
of nursing errors by nursing staff in home care services.
March 3, 2021
Jachan DE, Müller?Werdan U, Lahmann NA. Patient safety. Factors for and perceived consequences of
nursing errors by nursing staff in home care services. Nurs Open. 2021;8(2):755-765.
doi:1…
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psnet.ahrq.gov/node/44782/psn-pdf
January 13, 2016 - The Swiss cheese model of adverse event
occurrence—closing the holes.
January 13, 2016
Stein JE, Heiss K. The Swiss cheese model of adverse event occurrence--Closing the holes. Semin Pediatr
Surg. 2015;24(6):278-82. doi:10.1053/j.sempedsurg.2015.08.003.
https://psnet.ahrq.gov/issue/swiss-cheese-model-adverse-event…
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psnet.ahrq.gov/node/34801/psn-pdf
February 10, 2011 - Medication prescribing errors in a teaching hospital.
February 10, 2011
Lesar TS, Briceland LL, Delcoure K, et al. Medication prescribing errors in a teaching hospital. JAMA.
1990;263(17):2329-34.
https://psnet.ahrq.gov/issue/medication-prescribing-errors-teaching-hospital
This study analyzed nearly 290,000 medica…
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psnet.ahrq.gov/node/45987/psn-pdf
April 26, 2017 - Using simulation to prepare nursing staff for the move to
a new building.
April 26, 2017
Knippa S, Senecal P-A. Using Simulation to Prepare Nursing Staff for the Move to a New Building. J
Nurses Prof Dev. 2017;33(2):E1-E5. doi:10.1097/NND.0000000000000329.
https://psnet.ahrq.gov/issue/using-simulation-prepare-nurs…