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psnet.ahrq.gov/node/48052/psn-pdf
June 12, 2019 - How organisations contribute to improving the quality of
healthcare.
June 12, 2019
Fulop NJ, Ramsay AIG. How organisations contribute to improving the quality of healthcare. BMJ.
2019;365:l1773. doi:10.1136/bmj.l1773.
https://psnet.ahrq.gov/issue/how-organisations-contribute-improving-quality-healthcare
Quality a…
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psnet.ahrq.gov/node/35792/psn-pdf
March 22, 2006 - Make safety a priority: create and maintain a culture of
safety.
March 22, 2006
Leonard M; Frankel A.
https://psnet.ahrq.gov/issue/make-safety-priority-create-and-maintain-culture-safety
The authors discuss the development of a culture of safety and how accountability, physician and hospital
leadership, and commu…
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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/851462/psn-pdf
July 19, 2023 - Broken Trust: Making Patient Safety More than Just a
Promise.
July 19, 2023
Manchester, UK: Parliamentary and Health Service Ombudsman; June 2023. ISBN: 9781528642446.
https://psnet.ahrq.gov/issue/broken-trust-making-patient-safety-more-just-promise
Lack of accountability for systemic contributions to failure degr…
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psnet.ahrq.gov/training-catalog/ambulatory-care-conference-live-virtual
Ambulatory Care Conference - Live Virtual
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Organization:
Organization
Joint Commision Resources
Event Description: This 3 day live-…
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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/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/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/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/issue/improving-patient-safety-intensive-care-units-michigan
February 17, 2011 - Study
Classic
Improving patient safety in intensive care units in Michigan.
Citation Text:
Pronovost P, Berenholtz SM, Goeschel CA, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008;23(2):207-212. doi:10.1016/j.jcrc.2007.09…
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psnet.ahrq.gov/issue/impact-team-and-leaders-directed-strategy-improve-nurses-adherence-hand-hygiene-guidelines
November 19, 2009 - Study
Impact of a team and leaders-directed strategy to improve nurses' adherence to hand hygiene guidelines: a cluster randomised trial.
Citation Text:
Huis A, Schoonhoven L, Grol R, et al. Impact of a team and leaders-directed strategy to improve nurses' adherence to hand hygiene guid…
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psnet.ahrq.gov/issue/good-people-who-try-their-best-can-have-problems-recognition-human-factors-and-how-minimise
October 29, 2017 - Review
Good people who try their best can have problems: recognition of human factors and how to minimise error.
Citation Text:
Brennan PA, Mitchell DA, Holmes S, et al. Good people who try their best can have problems: recognition of human factors and how to minimise error. Br J Oral Ma…
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psnet.ahrq.gov/node/33718/psn-pdf
October 01, 2011 - In Conversation With… Paul G. Shekelle, MD, MPH, PhD
October 1, 2011
In Conversation With… Paul G. Shekelle, MD, MPH, PhD. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-paul-g-shekelle-md-mph-phd
Editor's note: Dr. Shekelle is director of the Southern California Evidence-Based Practice Cen…
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psnet.ahrq.gov/issue/patient-safety-alliance-tackle-hand-washing-worldwide
January 12, 2022 - Newspaper/Magazine Article
Patient safety alliance to tackle hand washing worldwide.
Citation Text:
Bristol N. Patient safety alliance to tackle hand washing worldwide. Lancet (London, England). 2005;366(9490):973-4.
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psnet.ahrq.gov/training-catalog/patient-safety-executive-development-program
Patient Safety Executive Development Program
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Organization:
Organization
Institute for Healthcare Improvement (IHI)
Event Description…
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psnet.ahrq.gov/node/39538/psn-pdf
May 19, 2010 - CPOE: strategies for success.
May 19, 2010
Manor PJ. CPOE: Strategies for success. Nurs Manage. 2010;41(5):18-20.
doi:10.1097/01.NUMA.0000372028.99240.7f.
https://psnet.ahrq.gov/issue/cpoe-strategies-success
This commentary reviews tactics to engage nurses in computerized provider order entry (CPOE)
implementatio…
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psnet.ahrq.gov/node/41351/psn-pdf
June 27, 2018 - Noah's story: please listen.
June 27, 2018
Lord T. Patient Saf Qual Healthc. March/April 2012;9:38-41,44.
https://psnet.ahrq.gov/issue/noahs-story-please-listen
This article details how miscommunication and lack of patient-centered care contributed to errors that led to
the death of a child.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/35007/psn-pdf
May 22, 2009 - Peripheral vision: expertise in real world contexts.
May 22, 2009
Dreyfus HL, Dreyfus SE. Peripheral Vision. Organization Studies. 2005;26(5).
doi:10.1177/0170840605053102.
https://psnet.ahrq.gov/issue/peripheral-vision-expertise-real-world-contexts
The authors describe a five-stage model of acquiring expertise an…
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psnet.ahrq.gov/node/33874/psn-pdf
February 01, 2019 - Building Systems Citizenship in Health Professions
Education: The Continued Call for Health Systems
Science Curricula
February 1, 2019
Gonzalo JD, Singh MK. Building Systems Citizenship in Health Professions Education: The Continued Call
for Health Systems Science Curricula. PSNet [internet]. 2019.
https://psnet.…
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psnet.ahrq.gov/node/836870/psn-pdf
April 26, 2022 - A Conversation Among Stakeholders on Medical
Malpractice.
April 6, 2022
Collaborative for Accountability and Improvement. April 26, 2022.
https://psnet.ahrq.gov/issue/conversation-among-stakeholders-medical-malpractice
Communication and resolution programs (CRP) can improve response to patients and families a…