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psnet.ahrq.gov/node/839330/psn-pdf
November 02, 2022 - Diagnosis: Reducing Errors and Improving Quality.
November 2, 2022
Schiff G. Chapter In: Loscalzo J, Fauci A, Kasper D, et al, eds. Harrison's Principles of Internal Medicine,
21e. New York, NY: McGraw Hill; 2022
https://psnet.ahrq.gov/issue/diagnosis-reducing-errors-and-improving-quality
The task of performing a …
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psnet.ahrq.gov/node/48144/psn-pdf
August 07, 2019 - Moving towards a Safety II approach.
August 7, 2019
Woodward S. Moving towards a safety II approach. J Patient Saf Risk Manag. 2019;24(3):96-99.
doi:10.1177/2516043519855264.
https://psnet.ahrq.gov/issue/moving-towards-safety-ii-approach
Efforts to improve patient safety have evolved beyond investigating what went…
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psnet.ahrq.gov/node/844055/psn-pdf
February 08, 2023 - National patient safety goal to improve health care equity.
February 8, 2023
R3 Report. December 20, 2022;38:1-8.
https://psnet.ahrq.gov/issue/national-patient-safety-goal-improve-health-care-equity
Health care inequities persist despite increasing awareness they negatively affect quality, safety, and
patient cent…
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psnet.ahrq.gov/node/48128/psn-pdf
August 28, 2019 - Burnout in healthcare: the case for organisational
change.
August 28, 2019
Montgomery A, Panagopoulou E, Esmail A, et al. Burnout in healthcare: the case for organisational
change. BMJ. 2019;366:l4774. doi:10.1136/bmj.l4774.
https://psnet.ahrq.gov/issue/burnout-healthcare-case-organisational-change
Burnout has be…
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psnet.ahrq.gov/node/47983/psn-pdf
May 01, 2019 - Health systems and hospitals in pursuit of high reliability.
May 1, 2019
Cheney C. HealthLeaders Media. April 17, 2019.
https://psnet.ahrq.gov/issue/health-systems-and-hospitals-pursuit-high-reliability
This news article describes how a 19-hospital health system successfully applied high reliability principles
to …
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psnet.ahrq.gov/node/33665/psn-pdf
March 01, 2008 - Creation of a Medical Procedure Service to Improve
Patient Safety
March 1, 2008
Smith CC, CHuang G. Creation of a Medical Procedure Service to Improve Patient Safety. PSNet [internet].
2008.
https://psnet.ahrq.gov/perspective/creation-medical-procedure-service-improve-patient-safety
Perspective
Introduction and …
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psnet.ahrq.gov/node/35088/psn-pdf
January 01, 2025 - National Patient Safety Goals.
November 26, 2024
The Joint Commission.
https://psnet.ahrq.gov/issue/national-patient-safety-goals
The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission
establishes standards for ensuring patient safety in all health care settings. In or…
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psnet.ahrq.gov/node/38000/psn-pdf
August 03, 2009 - The competitive imperative of learning.
August 3, 2009
Edmondson A. The competitive imperative of learning. Harv Bus Rev. 2008;86(7-8):60-7, 160.
https://psnet.ahrq.gov/issue/competitive-imperative-learning
This article draws on experience analyzing team behavior in hospitals to discuss how learning processes
can …
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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/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/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/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/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/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/training-catalog/ambulatory-care-conference
Ambulatory Care Conference
Save
Save to your library
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Organization:
Organization
Joint Commision Resources
Event Description: This two-day educat…
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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/38876/psn-pdf
April 04, 2011 - Reality check for checklists.
April 4, 2011
Bosk CL, Dixon-Woods M, Goeschel CA, et al. Reality check for checklists. Lancet. 2009;374(9688):444-5.
https://psnet.ahrq.gov/issue/reality-check-checklists
Discussing the impact of checklists in the broader context of frontline care, the authors emphasize that
achievin…
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psnet.ahrq.gov/node/848829/psn-pdf
May 10, 2023 - Lessons from the Covid War: An Investigative Report.
May 10, 2023
Covid Crisis Group. New York: Public Affairs; 2023. ISBN?: ?9781541703803.
https://psnet.ahrq.gov/issue/lessons-covid-war-investigative-report
The transfer of failure experiences to generate learning and improve service is a complicated responsibilit…
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psnet.ahrq.gov/node/60951/psn-pdf
September 23, 2020 - A Guide to Patient Safety Improvement: Integrating
Knowledge Translation & Quality Improvement
Approaches.
September 23, 2020
Edmonton, Alberta; Canadian Patient Safety Institute: 2020. ISBN: 9781926541846.
https://psnet.ahrq.gov/issue/guide-patient-safety-improvement-integrating-knowledge-translation-quality-
im…
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psnet.ahrq.gov/node/47647/psn-pdf
January 23, 2019 - Patient Safety: Global Action on Patient Safety.
January 23, 2019
Executive Board EB144/29 144th session. Geneva, Switzerland: World Health Organization; December 12,
2018.
https://psnet.ahrq.gov/issue/patient-safety-global-action-patient-safety
This guidance summarizes the current status of global patient safety,…