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psnet.ahrq.gov/node/34784/psn-pdf
June 24, 2015 - The potential for improved teamwork to reduce medical
errors in the emergency department.
June 24, 2015
Risser DT, Rice MM, Salisbury ML, et al. The potential for improved teamwork to reduce medical errors in
the emergency department. Ann Emerg Med. 2005;34(3):373-383. doi:10.1016/s0196-0644(99)70134-4.
https://ps…
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psnet.ahrq.gov/node/47002/psn-pdf
April 25, 2018 - Making Health Care Safer in Ambulatory Care Settings
and Long Term Care Facilities (R18).
April 25, 2018
Rockville, MD: Agency for Healthcare Research and Quality; April 10, 2018. PA-18-750.
https://psnet.ahrq.gov/issue/making-health-care-safer-ambulatory-care-settings-and-long-term-care-
facilities-r18
Research …
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psnet.ahrq.gov/node/46086/psn-pdf
August 30, 2017 - Quality and Safety in Nursing: a Competency Approach to
Improving Outcomes, Second Edition.
August 30, 2017
Sherwood G, Barnsteiner J, eds. Hoboken, NJ: Wiley-Blackwell; 2017. ISBN: 9781119151678.
https://psnet.ahrq.gov/issue/quality-and-safety-nursing-competency-approach-improving-outcomes-second-
edition
The Cr…
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psnet.ahrq.gov/node/45868/psn-pdf
January 31, 2018 - Increasing trainee reporting of adverse events with
monthly, trainee-directed review of adverse events.
January 31, 2018
Smith A, Hatoun J, Moses J. Increasing Trainee Reporting of Adverse Events With Monthly Trainee-
Directed Review of Adverse Events. Acad Pediatr. 2017;17(8):902-906. doi:10.1016/j.acap.2017.01.00…
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psnet.ahrq.gov/web-mm/snfs-opening-black-box
August 27, 2012 - Taking advantage of the opportunities will help us meet the goals of the "triple aim": improved care, … The triple aim: a golden opportunity for geriatrics. J Am Geriatr Soc. 2013;61:1808-1809.
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psnet.ahrq.gov/node/49648/psn-pdf
March 01, 2012 - visits, hospitalizations, and
outpatient visits.(5) Hospital-based transitional care interventions aim … These
calls aim to identify and resolve postdischarge issues such as problems understanding discharge
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psnet.ahrq.gov/node/73282/psn-pdf
January 01, 2022 - Effects of a refined evidence-based toolkit and mentored
implementation on medication reconciliation at 18
hospitals: results of the MARQUIS2 study.
May 19, 2021
Schnipper JL, Reyes Nieva H, Mallouk M, et al. Effects of a refined evidence-based toolkit and mentored
implementation on medication reconciliation at 18…
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psnet.ahrq.gov/node/50863/psn-pdf
February 05, 2020 - Patient safety in inpatient mental health settings: a
systematic review.
February 5, 2020
Thibaut BI, Dewa LH, Ramtale SC, et al. Patient safety in inpatient mental health settings: a systematic
review. BMJ Open. 2019;9(12):e030230. doi:10.1136/bmjopen-2019-030230.
https://psnet.ahrq.gov/issue/patient-safety-inpat…
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psnet.ahrq.gov/node/848817/psn-pdf
May 10, 2023 - Impact of patient safety climate on infection prevention
practices and healthcare worker and patient outcomes.
May 10, 2023
Hessels AJ, Guo J, Johnson CT, et al. Impact of patient safety climate on infection prevention practices
and healthcare worker and patient outcomes. Am J Infect Control. 2023;51(5):482-489.
d…
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psnet.ahrq.gov/innovations
February 26, 2025 - Innovations
The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …
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psnet.ahrq.gov/node/38347/psn-pdf
May 24, 2015 - Using Telehealth to Improve Quality and Safety: Findings
from the AHRQ Portfolio.
May 24, 2015
Dixon BE, Hook JM, McGowan JJ, for AHRQ National Resource Center for Health IT. Rockville, MD:
Agency for Healthcare Research and Quality; December 2008. AHRQ Publication No. 09-0012-EF.
https://psnet.ahrq.gov/issue/usin…
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psnet.ahrq.gov/node/34907/psn-pdf
August 03, 2009 - Physicians' views of interventions to reduce medical
errors: does evidence of effectiveness matter?
August 3, 2009
Rosen AB, Blendon RJ, DesRoches CM, et al. Physicians' views of interventions to reduce medical errors:
does evidence of effectiveness matter? Acad Med. 2005;80(2):189-92.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/45879/psn-pdf
July 02, 2017 - A hybrid methodology for modeling risk of adverse
events in complex health-care settings.
July 2, 2017
Kazemi R, Mosleh A, Dierks M. A Hybrid Methodology for Modeling Risk of Adverse Events in Complex
Health-Care Settings. Risk Anal. 2017;37(3):421-440. doi:10.1111/risa.12702.
https://psnet.ahrq.gov/issue/hybrid-m…
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psnet.ahrq.gov/node/35028/psn-pdf
May 27, 2011 - Medication errors and adverse drug events in pediatric
inpatients.
May 27, 2011
Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric
inpatients. JAMA. 2001;285(16):2114-20.
https://psnet.ahrq.gov/issue/medication-errors-and-adverse-drug-events-pediatric-inpatients
This p…
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psnet.ahrq.gov/node/38157/psn-pdf
October 22, 2008 - Contributing factors identified by hospital incident report
narratives.
October 22, 2008
Nuckols TK, Bell DS, Paddock SM, et al. Contributing factors identified by hospital incident report
narratives. Qual Saf Health Care. 2008;17(5):368-72. doi:10.1136/qshc.2007.023721.
https://psnet.ahrq.gov/issue/contributing-f…
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psnet.ahrq.gov/node/45218/psn-pdf
June 15, 2016 - Patient Safety and Quality Improvement Act of 2005--HHS
guidance regarding patient safety work product and
providers' external obligations.
June 15, 2016
Agency for Healthcare Research and Quality. Fed Regist. 2016;81(100);32655-32660.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005-hh…
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psnet.ahrq.gov/node/867438/psn-pdf
January 08, 2025 - Safety management within the scope of teaching practical
clinical skills: framing errors for cardiopulmonary
resuscitation training - a multi-arm randomized controlled
equivalence trial.
January 8, 2025
Schmidt M, Schauwinhold MT, Loeffler LAK, et al. Safety management within the scope of teaching
practical clini…
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psnet.ahrq.gov/node/866191/psn-pdf
June 26, 2024 - Quality improvement lessons learned from National
Implementation of the "Patient Safety Events in
Community Care: Reporting, Investigation, and
Improvement Guidebook".
June 26, 2024
Sullivan JL, Shin MH, Chan J, et al. Quality improvement lessons learned from National Implementation of
the “Patient Safety Events …
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psnet.ahrq.gov/node/44948/psn-pdf
February 14, 2017 - Safer Healthcare: Strategies for the Real World.
February 14, 2017
Vincent C, Amalberti R. New York, NY: SpringerOpen; 2016
https://psnet.ahrq.gov/issue/safer-healthcare-strategies-real-world
Written by two leaders in the patient safety field, Charles Vincent and Rene Amalberti, this book is available
for free dow…
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psnet.ahrq.gov/node/44804/psn-pdf
November 18, 2016 - The Safer Delivery of Surgical Services Program (S3):
explaining its differential effectiveness and exploring
implications for improving quality in complex systems.
November 18, 2016
Flynn LC, McCulloch P, Morgan LJ, et al. The Safer Delivery of Surgical Services Program (S3): Explaining
Its Differential Effective…