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psnet.ahrq.gov/issue/effectiveness-improving-healthcare-teams-human-factor-skills-using-simulation-based-training
June 08, 2022 - Review
The effectiveness of improving healthcare teams' human factor skills using simulation-based training: a systematic review.
Citation Text:
Abildgren L, Lebahn-Hadidi M, Mogensen CB, et al. The effectiveness of improving healthcare teams’ human factor skills using simulation-based t…
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psnet.ahrq.gov/issue/using-incident-reports-assess-communication-failures-and-patient-outcomes
February 06, 2019 - Study
Using incident reports to assess communication failures and patient outcomes.
Citation Text:
Umberfield E, Ghaferi AA, Krein SL, et al. Using Incident Reports to Assess Communication Failures and Patient Outcomes. Jt Comm J Qual Patient Saf. 2019;45(6):406-413. doi:10.1016/j.jcjq.2…
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psnet.ahrq.gov/issue/missed-opportunities-diagnosing-brain-tumours-primary-care-qualitative-study-patient
August 04, 2021 - Study
Missed opportunities for diagnosing brain tumours in primary care: a qualitative study of patient experiences.
Citation Text:
Walter FM, Penfold C, Joannides A, et al. Missed opportunities for diagnosing brain tumours in primary care: a qualitative study of patient experiences. Br…
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psnet.ahrq.gov/node/867190/psn-pdf
November 20, 2024 - Misdiagnosis is dangerous. Help your doctor get it right.
November 20, 2024
Terry K. Misdiagnosis is dangerous. Help your doctor get it right. WebMD. November 11, 2024;
https://psnet.ahrq.gov/issue/misdiagnosis-dangerous-help-your-doctor-get-it-right
Patients are partners in health care and can inform actions to id…
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psnet.ahrq.gov/node/38480/psn-pdf
July 15, 2013 - Creative education for rapid response team
implementation.
July 15, 2013
Johnson AL. Creative education for rapid response team implementation. J Contin Educ Nurs.
2009;40(1):38-42.
https://psnet.ahrq.gov/issue/creative-education-rapid-response-team-implementation
This article describes how one community hospital…
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psnet.ahrq.gov/node/853445/psn-pdf
December 15, 2022 - Jake Tapper shares harrowing story of daughter's near-
fatal misdiagnosis.
December 15, 2022
CNN. December 15, 2022.
https://psnet.ahrq.gov/issue/jake-tapper-shares-harrowing-story-daughters-near-fatal-misdiagnosis
Diagnostic errors are a recognized cause of preventable patient harm. This video highlights a teen…
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psnet.ahrq.gov/issue/teamstepps-refresher-course
September 26, 2023 - September 13, 2023
Videos of simulated after action reviews: a training resource to support
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psnet.ahrq.gov/node/41469/psn-pdf
October 19, 2012 - Deconstructing intraoperative communication failures.
October 19, 2012
Hu Y-Y, Arriaga AF, Peyre S, et al. Deconstructing intraoperative communication failures. J Surg Res.
2012;177(1):37-42. doi:10.1016/j.jss.2012.04.029.
https://psnet.ahrq.gov/issue/deconstructing-intraoperative-communication-failures
Video reco…
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psnet.ahrq.gov/node/844792/psn-pdf
January 01, 2020 - Surgical data recording technology: a solution to address
medical errors?
September 18, 2019
Shah NA, Jue J, Mackey T. Surgical Data Recording Technology. Ann Surg. 2020;271(3):431-433.
doi:10.1097/sla.0000000000003510.
https://psnet.ahrq.gov/issue/surgical-data-recording-technology-solution-address-medical-errors…
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psnet.ahrq.gov/node/50374/psn-pdf
September 25, 2019 - Explainable artificial intelligence for safe intraoperative
decision support.
September 25, 2019
Gordon L, Grantcharov T, Rudzicz F. Explainable Artificial Intelligence for Safe Intraoperative Decision
Support. JAMA Surg. 2019. doi:10.1001/jamasurg.2019.2821.
https://psnet.ahrq.gov/issue/explainable-artificial-int…
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psnet.ahrq.gov/issue/randomised-controlled-trial-assess-effect-just-time-training-procedural-performance-proof
May 31, 2017 - Study
Randomised controlled trial to assess the effect of a Just-in-Time training on procedural performance: a proof-of-concept study to address procedural skill decay.
Citation Text:
Branzetti JB, Adedipe AA, Gittinger MJ, et al. Randomised controlled trial to assess the effect of a Jus…
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psnet.ahrq.gov/innovation/echo-care-transitions-successfully-reduces-patient-readmissions-skilled-nursing
October 30, 2024 - ECHO-Care Transitions Successfully Reduces Patient Readmissions from Skilled Nursing Facilities, Reduces Length of Stay
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August 25, 2021
Innova…
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psnet.ahrq.gov/issue/proficiency-based-virtual-reality-training-significantly-reduces-error-rate-residents-during
November 13, 2009 - Study
Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies.
Citation Text:
Ahlberg G, Enochsson L, Gallagher AG, et al. Proficiency-based virtual reality training significantly reduces the err…
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psnet.ahrq.gov/node/867748/psn-pdf
March 12, 2025 - Adverse events involving telehealth in the Veterans
Health Administration.
March 12, 2025
Mills PD, Tomolo A, Yackel EE. Adverse events involving telehealth in the Veterans Health Administration.
Jt Comm J Qual Patient Saf. 2024;Epub Dec 20. doi:10.1016/j.jcjq.2024.12.002.
https://psnet.ahrq.gov/issue/adverse-even…
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psnet.ahrq.gov/node/846162/psn-pdf
July 01, 2020 - The effect of virtual nursing and missed nursing care.
July 1, 2020
Schuelke S, Aurit S, Connot N, et al. The effect of virtual nursing and missed nursing care. Nurs Adm Q.
2020;44(3):280-287. doi:10.1097/naq.0000000000000419.
https://psnet.ahrq.gov/issue/effect-virtual-nursing-and-missed-nursing-care
The COVID-19…
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psnet.ahrq.gov/node/43739/psn-pdf
December 03, 2014 - Joshua’s Story.
December 3, 2014
Anderson-Wallace M, Denning R. Leeds, UK: Patient Stories; October 18, 2014.
https://psnet.ahrq.gov/issue/joshuas-story
Patient stories are a growing component of understanding the impact of medical errors on patients and
uncovering underlying causes. This video features an in-dept…
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psnet.ahrq.gov/node/42005/psn-pdf
January 30, 2013 - Infusing fun into quality and safety initiatives.
January 30, 2013
Foulk KC, Tocydlowski P, Snow TM, et al. Infusing fun into quality and safety initiatives. Nursing (Brux).
2012;42(11):14-16. doi:10.1097/01.NURSE.0000421386.36112.a9.
https://psnet.ahrq.gov/issue/infusing-fun-quality-and-safety-initiatives
Nursing…
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psnet.ahrq.gov/primer/health-literacy
September 07, 2019 - information : Communicate clearly with plain language and visual cues, such as models, pictures, or videos
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psnet.ahrq.gov/web-mm/nosy-business
March 01, 2007 - Nosy Business
Citation Text:
Orlandi RR. Nosy Business. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/42403/psn-pdf
August 02, 2015 - Encouraging patients to ask questions: how to overcome
"white-coat silence."
August 2, 2015
Judson TJ, Detsky AS, Press MJ. Encouraging patients to ask questions: how to overcome "white-coat
silence". JAMA. 2013;309(22):2325-6. doi:10.1001/jama.2013.5797.
https://psnet.ahrq.gov/issue/encouraging-patients-ask-quest…