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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844791/psn-pdf
    September 18, 2019 - Review of alternatives to root cause analysis: developing a robust system for incident report analysis. September 18, 2019 Hagley G, Mills PD, Watts B, et al. Review of alternatives to root cause analysis: developing a robust system for incident report analysis. BMJ Open Qual. 2019;8(3):e000646. doi:10.1136/bmjoq-2…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50423/psn-pdf
    September 04, 2019 - When a vital sign leads a country astray—the opioid epidemic. September 4, 2019 Chidgey BA, McGinigle KL, McNaull PP. When a Vital Sign Leads a Country Astray—The Opioid Epidemic. JAMA Surg. 2019;154(11):987-988. doi:10.1001/jamasurg.2019.2104. https://psnet.ahrq.gov/issue/when-vital-sign-leads-country-astray-opio…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48102/psn-pdf
    August 07, 2019 - The unmeasured quality metric: burn out and the second victim syndrome in healthcare. August 7, 2019 Heiss K, Clifton M. The unmeasured quality metric: Burn out and the second victim syndrome in healthcare. Semin Pediatr Surg. 2019;28(3):189-194. doi:10.1053/j.sempedsurg.2019.04.011. https://psnet.ahrq.gov/issue/u…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45520/psn-pdf
    October 05, 2016 - Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic error. October 5, 2016 Foster PN, Klein JR. Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic error. J Community Hosp Intern Med Perspect. 2016;6(4):31994. doi:10.3402/jchimp.v6.31994. http…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45592/psn-pdf
    October 27, 2016 - Preventing Patient Falls: A Systematic Approach From the Joint Commission Center for Transforming Healthcare Project. October 27, 2016 Chicago, IL: Health Research & Educational Trust; October 2016. https://psnet.ahrq.gov/issue/preventing-patient-falls-systematic-approach-joint-commission-center- transforming-hea…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60007/psn-pdf
    March 04, 2020 - ISMP Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps. March 4, 2020 Horsham, PA: Institute for Safe Medication Practices; 2020. https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-implementation-and-use-smart-infusion- pumps Smart pumps are widely available as a medicat…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45609/psn-pdf
    November 16, 2016 - A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy. November 16, 2016 Giardina M, Cantone MC, Tomarchio E, et al. A Review of Healthcare Failure Mode and Effects Analysis (HFMEA) in Radiotherapy. Health Phys. 2016;111(4):317-26. doi:10.1097/HP.0000000000000536. https://psnet.ahrq.gov/…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45249/psn-pdf
    June 22, 2016 - PHSO Review: Quality of NHS Complaints Investigations. June 22, 2016 First Report of Session 2016–17 Report. House of Commons Public Administration and Constitutional Affairs Committee. London, England: The Stationery Office; May 24, 2016. Publication HC 94. https://psnet.ahrq.gov/issue/phso-review-quality-nhs-comp…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37883/psn-pdf
    July 02, 2008 - The limits of knowledge management for UK public services modernization: the case of patient safety and service quality. July 2, 2008 Currie G, Waring J, Finn R. THE LIMITS OF KNOWLEDGE MANAGEMENT FOR UK PUBLIC SERVICES MODERNIZATION: THE CASE OF PATIENT SAFETY AND SERVICE QUALITY. Public Adm. 2008;86(2). doi:10.…

  10. USA, VA, Arlington | Digital Healthcare Research

    digital.ahrq.gov/location/usa-va-arlington
    January 01, 2023 - USA, VA, Arlington Personal Health Information Management and Design of Consumer Health IT Description The purpose of this project was to establish a foundation and propose an action agenda for the integration of patients’ personal health information management into the design…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45298/psn-pdf
    April 22, 2017 - The problem with root cause analysis. April 22, 2017 Peerally MF, Carr S, Waring J, et al. The problem with root cause analysis. BMJ Qual Saf. 2017;26(5):417- 422. doi:10.1136/bmjqs-2016-005511. https://psnet.ahrq.gov/issue/problem-root-cause-analysis Root cause analysis (RCA) is a strategy to investigate incident…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44821/psn-pdf
    December 05, 2022 - Action Planning Tool for the AHRQ Surveys on Patient Safety Culture. December 5, 2022 Yount N, Edelman S, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; November 2022. AHRQ Publication No. 23-0011. https://psnet.ahrq.gov/issue/action-planning-tool-ahrq-surveys-patient-safety-culture Im…

  13. Materials by Topic | Agency for Healthcare Research and Quality

    www.ahrq.gov/nursing-home/materials/index.html
    March 01, 2022 - Materials by Topic Following are selected COVID-19 nursing home safety and quality improvement resources for nursing homes on a range of topics including preventing the spread of COVID-19, vaccination, leadership, management and quality improvement, and staff and resident well-being. Preventing the Spread o…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48189/psn-pdf
    August 14, 2019 - Professionalism lapses and adverse childhood experiences: reflections from the island of last resort. August 14, 2019 Williams BW. Professionalism Lapses and Adverse Childhood Experiences: Reflections From the Island of Last Resort. Acad Med. 2019;94(8):1081-1083. doi:10.1097/ACM.0000000000002793. https://psnet.ah…

  15. Advancing Patient Safety | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/reports/advancing-patient-safety.html
    March 01, 2024 - Advancing Patient Safety Advancing Patient Safety: A Decade of Evidence, Design, and Implementation This document highlights some of the Agency's contributions in advancing patient safety during the past decade. Advances in Patient Safety: From Research to Implementation This four-volume set from AHRQ and t…

  16. Bckgrndqiteam (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/bckgrndqiteam.doc
    June 02, 2025 - Background Quality Improvement Team Information Form Who should use this tool? Health care providers. Please indicate people designated as Quality Improvement Team Members. Your team may not have people who serve in all of these roles. These individuals from are members of the Qual…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44231/psn-pdf
    January 22, 2016 - Just-in-time training for high-risk low-volume therapies: an approach to ensure patient safety. January 22, 2016 Helman S, Lisanti AJ, Adams A, et al. Just-in-Time Training for High-Risk Low-Volume Therapies: An Approach to Ensure Patient Safety. J Nurs Care Qual. 2016;31(1):33-9. doi:10.1097/NCQ.0000000000000131.…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46482/psn-pdf
    October 11, 2017 - What can physicians do to help curb the opioid crisis? October 11, 2017 Bendix J. https://psnet.ahrq.gov/issue/what-can-physicians-do-help-curb-opioid-crisis The persistent problem of opioid-related harm calls for changes in pain management practices and system processes in all care settings. This magazine article…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46741/psn-pdf
    June 07, 2018 - Suffering in silence: medical error and its impact on health care providers. June 7, 2018 Robertson JJ, Long B. Suffering in Silence: Medical Error and its Impact on Health Care Providers. J Emerg Med. 2018;54(4). doi:10.1016/j.jemermed.2017.12.001. https://psnet.ahrq.gov/issue/suffering-silence-medical-error-and-…

  20. Minnesota Pharmacy Practice-Based Research Network | Agency for Healthcare Research and Quality

    www.ahrq.gov/ncepcr/communities/pbrn/registry/minnesota-pharmacy-practice-based-research-network.html
    January 01, 2012 - Minnesota Pharmacy Practice-Based Research Network Status: Active Registered Date: January 1, 2012 PBRN Acronym: Minnesota Pharmacy PBRN PBRN Type: Pharmacy Network (at least 75% are pharmacists) Network Category: Affiliate City: Minneapolis State: Minnesota…
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