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psnet.ahrq.gov/issue/crisis-management-during-anaesthesia-development-anaesthetic-crisis-management-manual
June 23, 2015 - Commentary
Crisis management during anaesthesia: the development of an anaesthetic crisis management manual.
Citation Text:
Runciman WB, Kluger MT, Morris RW, et al. Crisis management during anaesthesia: the development of an anaesthetic crisis management manual. Qual Saf Health Care. …
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psnet.ahrq.gov/node/50876/psn-pdf
April 22, 2021 - Veterans Accountability Improvement Act.
April 22, 2021
SB 1307, 117th Congress: 2021.
https://psnet.ahrq.gov/issue/veterans-accountability-improvement-act
Reporting clinicians who exhibit practice behaviors that are detrimental to safety is challenged by system
and cultural norms. This legislation aims to strengt…
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psnet.ahrq.gov/node/40502/psn-pdf
January 01, 2020 - New 2012 National Patient Safety Goal - catheter-
associated urinary tract infection (CAUTI).
June 1, 2011
Joint Commission.
https://psnet.ahrq.gov/issue/new-2012-national-patient-safety-goal-catheter-associated-urinary-tract-
infection-cauti
This announcement reveals the new National Patient Safety Goal for 2012…
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psnet.ahrq.gov/node/846765/psn-pdf
March 29, 2023 - Addressing Medical Gaslighting to Improve Maternal
Health—Together.
March 29, 2023
Oregon Patient Safety Commission: 2023.
https://psnet.ahrq.gov/issue/addressing-medical-gaslighting-improve-maternal-health-together
Gaslighting has been identified as a contributor to maternal mortality and morbidity. This toolkit …
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psnet.ahrq.gov/node/50939/psn-pdf
February 26, 2020 - Homecare safety virtual quality improvement
collaboratives
February 26, 2020
Miller W, Asselbergs M, Bank J, et al. Homecare safety virtual quality improvement collaboratives. Healthc
Q. 2020;22(SP). doi:10.12927/hcq.2020.26042.
https://psnet.ahrq.gov/issue/homecare-safety-virtual-quality-improvement-collaborative…
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psnet.ahrq.gov/node/37829/psn-pdf
April 23, 2014 - Hospitals move to reduce risk of night shift.
April 23, 2014
Landro L.
https://psnet.ahrq.gov/issue/hospitals-move-reduce-risk-night-shift
This article reports how hospitals are aiming to boost the safety of care delivered on nights and weekends
by employing "nocturnists" (a hospitalist subspecialty)—physicians wh…
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psnet.ahrq.gov/node/838925/psn-pdf
March 03, 2025 - Improving Quality and Safety in Healthcare.
March 3, 2025
Dixon-Woods M, Martin G, eds. Cambridge, UK: Cambridge University Press; 2022-2025.
https://psnet.ahrq.gov/issue/improving-quality-and-safety-healthcare
Improvement activities are complex initiatives that require synergistic actions by organizations to be
s…
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psnet.ahrq.gov/node/42557/psn-pdf
August 28, 2013 - European Union Network for Patient Safety and Quality of
Care.
August 28, 2013
European Union Network for Patient Safety and Quality of Care; PaSQ.
https://psnet.ahrq.gov/issue/european-union-network-patient-safety-and-quality-care
This organization aims to promote implementation of recommended patient safety prac…
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psnet.ahrq.gov/node/848828/psn-pdf
May 10, 2023 - Nurse Staffing Standards for Hospital Patient Safety and
Quality Care Act of 2023.
May 10, 2023
118th Cong (2023-2024).
https://psnet.ahrq.gov/issue/nurse-staffing-standards-hospital-patient-safety-and-quality-care-act-2023
Nurse staffing and patient care outcomes are linked, yet variation exists in nursing covera…
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psnet.ahrq.gov/node/50577/psn-pdf
October 23, 2019 - Medicare's Oversight of Ambulatory Surgery Centers
Report.
October 23, 2019
Washington, DC: Office of the Inspector General; September 2019. Report No. OEI-01-15-00400.
https://psnet.ahrq.gov/issue/medicares-oversight-ambulatory-surgery-centers-report
Ambulatory surgery centers (ASC) play an increasing role in com…
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psnet.ahrq.gov/node/47533/psn-pdf
June 19, 2019 - Patient Safety: A Health Affairs Briefing.
June 19, 2019
Project Hope.
https://psnet.ahrq.gov/issue/patient-safety-health-affairs-briefing
To Err Is Human was released almost 2 decades ago and continues to influence a growing area of study
aimed at improving health care and reducing medical error. This in-person a…
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psnet.ahrq.gov/sites/default/files/2021-09/Battle%20Buddy%20Pocket%20Card%20-%20final%20(1).pdf
January 01, 2021 - Military Medicine 184,:114, 2019
Aim to contact your Battle
Buddy 2-3 times per week or
more (daily
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psnet.ahrq.gov/node/36934/psn-pdf
September 01, 2011 - Recurrent wrong-route drug error – a professional shame.
September 1, 2011
Bell D. Recurrent wrong-route drug error - a professional shame. Anaesthesia. 2007;62(6):541-5.
https://psnet.ahrq.gov/issue/recurrent-wrong-route-drug-error-professional-shame
Referencing three case studies from the same issue, the author d…
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psnet.ahrq.gov/node/35247/psn-pdf
December 17, 2008 - Review of the Australian Incident Monitoring System.
December 17, 2008
Spigelman AD, Swan J. Review of the Australian incident monitoring system. ANZ J Surg. 2005;75(8):657-
61.
https://psnet.ahrq.gov/issue/review-australian-incident-monitoring-system
The authors surveyed users of the Australian Incident Monitorin…
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psnet.ahrq.gov/node/34009/psn-pdf
November 12, 2014 - Consumer Safe Medicine.
November 12, 2014
Plymouth Meeting, PA; Institute for Safe Medication Practices.
https://psnet.ahrq.gov/issue/ismps-safe-medicine
ISMP's electronic consumer medication safety newsletter is published six times a year and its content aims
to engage patients and families in reducing medication…
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psnet.ahrq.gov/issue/influence-organizational-climate-and-clinician-morale-seclusion-and-physical-restraint-use
August 21, 2018 - Study
Influence of organizational climate and clinician morale on seclusion and physical restraint use in inpatient psychiatric units.
Citation Text:
Anderson E, Mohr DC, Regenbogen I, et al. Influence of organizational climate and clinician morale on seclusion and physical restraint use…
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psnet.ahrq.gov/node/39737/psn-pdf
November 30, 2016 - Physician's Guide to Patient Safety Organizations.
November 30, 2016
Chicago, IL: American Medical Association; 2009.
https://psnet.ahrq.gov/issue/physicians-guide-patient-safety-organizations
This guide reviews the Patient Safety Quality and Improvement Act of 2005 and aims to further physician
knowledge of and p…
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psnet.ahrq.gov/node/867650/psn-pdf
January 01, 2022 - Opioid deprescribing toolkit.
January 1, 2022
Health Innovation East, National Health Service. Opioid deprescribing toolkit.
https://psnet.ahrq.gov/issue/opioid-deprescribing-toolkit
Sudden discontinuation of long-term prescription opioid use can lead to adverse outcomes for patients.
Based on research and clinici…
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psnet.ahrq.gov/node/73359/psn-pdf
June 02, 2020 - Patient Safety Movement Foundation.
June 2, 2020
15642 Sand Canyon Ave. #51268, Irvine, CA 92619. 877-236-0279, info@psmf.org.
https://psnet.ahrq.gov/issue/patient-safety-movement-foundation
This organization shares best practices to align and optimize efforts toward eliminating patient harm by the
…
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psnet.ahrq.gov/node/837979/psn-pdf
August 31, 2022 - Maternal Health Research Centers of Excellence (U54
Clinical Trial Optional).
August 31, 2022
National Institutes of Health. August 11, 2022. RFA-HD-23-035.
https://psnet.ahrq.gov/issue/maternal-health-research-centers-excellence-u54-clinical-trial-optional
Maternity care is increasingly being recognized as …