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psnet.ahrq.gov/node/33644/psn-pdf
December 01, 2006 - Establishing a Safety Culture: Thinking Small
December 1, 2006
Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
Perspective
Safety cultures are the holy grail in any risky industry. Like all holy grails, th…
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psnet.ahrq.gov/node/866697/psn-pdf
September 11, 2024 - Patient Safety: Emerging Applications of Safety Science.
September 11, 2024
Cox C, Hughes H, Nicholls J. Patient Safety: Emerging Applications Of Safety Science. Somerset, UK:
Class Publishing; 2024. ISBN 9781801610834.
https://psnet.ahrq.gov/issue/patient-safety-emerging-applications-safety-science
Patient safety…
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psnet.ahrq.gov/node/867394/psn-pdf
March 10, 2025 - Request for Information: Diagnostic Excellence
Measurement.
December 18, 2024
Request for Information: Diagnostic Excellence Measurement. Agency for Healthcare Research and
Quality. Fed Register. December 12, 2024;89:100497-100498.
https://psnet.ahrq.gov/issue/request-information-diagnostic-excellence-measurement
…
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psnet.ahrq.gov/node/848105/psn-pdf
April 26, 2023 - GoodDx.org
April 26, 2023
GoodDx.
https://psnet.ahrq.gov/issue/gooddxorg
Effective feedback is an important component of individual, team and organizational learning in order to
achieve safe diagnosis. GoodDx.org houses a variety of diagnostic performance feedback resources for
use by clinicians, patient safety p…
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psnet.ahrq.gov/issue/first-do-no-harm-marshaling-clinician-leadership-counter-opioid-epidemic
July 19, 2017 - Book/Report
First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic.
Citation Text:
First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic. Adams SM, Blanco C, Chaudhry HJ, et al. Washington, DC: National Academy of Medicine; 2017. ISB…
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psnet.ahrq.gov/issue/essential-activities-electronic-health-record-safety-qualitative-study
April 29, 2018 - Study
Essential activities for electronic health record safety: a qualitative study.
Citation Text:
Ash JS, Singh H, Wright A, et al. Essential activities for electronic health record safety: A qualitative study. Health Informatics J. 2019:1460458219833109. doi:10.1177/1460458219833109. …
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psnet.ahrq.gov/issue/current-challenges-health-information-technology-related-patient-safety
July 16, 2015 - Commentary
Current challenges in health information technology–related patient safety.
Citation Text:
Sittig DF, Wright A, Coiera E, et al. Current challenges in health information technology–related patient safety. Health Inform J. 2020;26(1):181-189. doi:10.1177/1460458218814893.
Cop…
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psnet.ahrq.gov/issue/preventing-medication-errors-quality-chasm-series
January 04, 2009 - Book/Report
Classic
Preventing Medication Errors: Quality Chasm Series.
Citation Text:
Preventing Medication Errors: Quality Chasm Series. Aspden P, Wolcott J, Bootman JL, et al, eds; Institute of Medicine, Committee on Identifying and Preventing Medication …
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psnet.ahrq.gov/issue/optimizing-transitions-care-reduce-rehospitalizations
November 04, 2015 - Review
Optimizing transitions of care to reduce rehospitalizations.
Citation Text:
Li J, Young R, Williams M. Optimizing transitions of care to reduce rehospitalizations. Cleve Clin J Med. 2014;81(5):312-20. doi:10.3949/ccjm.81a.13106.
Copy Citation
Format:
DOI Google Schol…
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psnet.ahrq.gov/issue/limits-safety-organizations-accidents-and-nuclear-weapons
July 28, 2013 - Book/Report
Classic
The Limits of Safety: Organizations, Accidents and Nuclear Weapons.
Citation Text:
The Limits of Safety: Organizations, Accidents and Nuclear Weapons. Sagan SD. Princeton NJ: Princeton University Press; 1993. ISBN: 9780691032214.
Copy Cit…
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psnet.ahrq.gov/node/866257/psn-pdf
July 25, 2024 - Enhancing Surgical Team Communication: SOPS and
TeamSTEPPS in Action.
July 10, 2024
Agency for Healthcare Research and Quality. July 25, 2024.
https://psnet.ahrq.gov/issue/enhancing-surgical-team-communication-sops-and-teamstepps-action
Teamwork in the surgical suite is core to safe care but can be challenging to …
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psnet.ahrq.gov/issue/utilising-improvement-science-methods-optimise-medication-reconciliation
July 24, 2017 - Study
Utilising improvement science methods to optimise medication reconciliation.
Citation Text:
White CM, Schoettker PJ, Conway PH, et al. Utilising improvement science methods to optimise medication reconciliation. BMJ Qual Saf. 2011;20(4):372-80. doi:10.1136/bmjqs.2010.047845.
Co…
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psnet.ahrq.gov/node/74069/psn-pdf
September 20, 2022 - Diagnostic Excellence.
September 20, 2022
JAMA. Nov 2021-Sep 2022.
https://psnet.ahrq.gov/issue/diagnostic-excellence-0
Diagnostic excellence achievement is becoming a primary focus in health care. This 20-article series
covers diagnosis as it relates to the Institute of Medicine quality domains, clinical ch…
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psnet.ahrq.gov/node/841489/psn-pdf
December 14, 2022 - Rise to Health Coalition.
December 14, 2022
Boston, MA; Institute for Healthcare Improvement: December 2022.
https://psnet.ahrq.gov/issue/rise-health-coalition
Systemic efforts to improve health equity support patient safety. This announcement highlights an initiative
for collective work to address four areas of e…
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psnet.ahrq.gov/node/864865/psn-pdf
March 20, 2024 - The Top Five: A Review of Post-Pandemic Patient Safety
Priorities.
March 20, 2024
Sacramento, CA: Hospital Quality Institute; 2024.
https://psnet.ahrq.gov/issue/top-five-review-post-pandemic-patient-safety-priorities
The COVID pandemic posed wide-ranging challenges to both society at large as well as to the health…
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psnet.ahrq.gov/node/865347/psn-pdf
March 27, 2024 - Safety and Human Performance in the Operating Room
and Other Extreme Environments.
March 27, 2024
Ruskin KJ, ed. Int Anesthesiol Clin. 2024;62(2):1-65.
https://psnet.ahrq.gov/issue/safety-and-human-performance-operating-room-and-other-extreme-
environments
Anesthesia is a vital component of surgical care that can…
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psnet.ahrq.gov/node/60008/psn-pdf
July 09, 2024 - IHI Patient Safety Congress.
July 9, 2024
Institute for Healthcare Improvement. San Diego, CA, March 10-11, 2025.
https://psnet.ahrq.gov/issue/ihi-patient-safety-congress
This annual conference will host pre-session workshops, panels, and presentations covering a variety of
patient safety topics that ali…
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psnet.ahrq.gov/node/866072/psn-pdf
June 05, 2024 - WHO Global Report on Patient Safety.
June 5, 2024
Geneva, Switzerland: World Health Organization; 2024. ISBN 9789240095458.
https://psnet.ahrq.gov/issue/who-global-report-patient-safety
Comparative data can help to inform and motivate patient safety improvement efforts. This report uses the
seven objectives of the…
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psnet.ahrq.gov/node/854639/psn-pdf
October 18, 2023 - Right Kind of Wrong: Why Learning to Fail can Teach us
to Thrive.
October 18, 2023
Edmondson A. Atria Books, New York, 2023. ISBN: 9781982195069.
https://psnet.ahrq.gov/issue/right-kind-wrong-why-learning-fail-can-teach-us-thrive
Despite the harm that failure can cause, its value as a learning opportunity, if exam…
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psnet.ahrq.gov/node/42080/psn-pdf
February 27, 2013 - Transitions of Care (TOC) Portal.
February 27, 2013
https://psnet.ahrq.gov/issue/transitions-care-toc-portal
This Web site provides resources for clinicians and patients to help achieve safe care transitions.
https://psnet.ahrq.gov/issue/transitions-care-toc-portal
https://psnet.ahrq.gov/issue/improving-transitions…