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psnet.ahrq.gov/node/42208/psn-pdf
April 17, 2013 - Hospital staff nurses' shift length associated with safety
and quality of care.
April 17, 2013
Stimpfel AW, Aiken LH. Hospital staff nurses' shift length associated with safety and quality of care. J Nurs
Care Qual. 2013;28(2):122-129. doi:10.1097/NCQ.0b013e3182725f09.
https://psnet.ahrq.gov/issue/hospital-staff-n…
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psnet.ahrq.gov/node/38175/psn-pdf
April 11, 2011 - An intervention to decrease narcotic-related adverse drug
events in children's hospitals.
April 11, 2011
Sharek PJ, McClead RE, Taketomo C, et al. An intervention to decrease narcotic-related adverse drug
events in children's hospitals. Pediatrics. 2008;122(4):e861-e866. doi:10.1542/peds.2008-1011.
https://psnet.a…
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psnet.ahrq.gov/node/41942/psn-pdf
July 24, 2017 - Improving situation awareness to reduce unrecognized
clinical deterioration and serious safety events.
July 24, 2017
Brady PW, Muething S, Kotagal U, et al. Improving situation awareness to reduce unrecognized clinical
deterioration and serious safety events. Pediatrics. 2013;131(1):e298-308. doi:10.1542/peds.2012-…
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psnet.ahrq.gov/node/38660/psn-pdf
November 13, 2009 - Improving medication error reporting in hospice care.
November 13, 2009
Boyer R, McPherson ML, Deshpande G, et al. Improving medication error reporting in hospice care. Am J
Hosp Palliat Care. 2009;26(5):361-7. doi:10.1177/1049909109335145.
https://psnet.ahrq.gov/issue/improving-medication-error-reporting-hospice-c…
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psnet.ahrq.gov/node/43436/psn-pdf
August 13, 2014 - Decreasing handoff-related care failures in children's
hospitals.
August 13, 2014
Bigham MT, Logsdon TR, Manicone PE, et al. Decreasing handoff-related care failures in children's
hospitals. Pediatrics. 2014;134(2):e572-e579. doi:10.1542/peds.2013-1844.
https://psnet.ahrq.gov/issue/decreasing-handoff-related-care-…
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psnet.ahrq.gov/node/43101/psn-pdf
May 30, 2014 - Instituting a culture of professionalism: the establishment
of a Center for Professionalism and Peer Support.
May 30, 2014
Shapiro J, Whittemore A, Tsen LC. Instituting a culture of professionalism: the establishment of a center for
professionalism and peer support. Jt Comm J Qual Patient Saf. 2014;40(4):168-177.
…
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psnet.ahrq.gov/node/43567/psn-pdf
October 21, 2016 - National Action Plan for Adverse Drug Event Prevention.
October 21, 2016
Washington, DC: Office of Disease Prevention and Health Promotion, United States Department of Health
and Human Services; September 2014.
https://psnet.ahrq.gov/issue/national-action-plan-adverse-drug-event-prevention
This national action pla…
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psnet.ahrq.gov/node/42219/psn-pdf
July 22, 2013 - Parent perceptions of children's hospital safety climate.
July 22, 2013
Cox E, Carayon P, Hansen KW, et al. Parent perceptions of children's hospital safety climate. BMJ Qual
Saf. 2013;22(8):664-71. doi:10.1136/bmjqs-2012-001727.
https://psnet.ahrq.gov/issue/parent-perceptions-childrens-hospital-safety-climate
Pat…
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psnet.ahrq.gov/node/50426/psn-pdf
January 01, 2020 - Community pharmacy medication review, death and re-
admission after hospital discharge: a propensity score-
matched cohort study.
September 4, 2019
Lapointe-Shaw L, Bell CM, Austin PC, et al. Community pharmacy medication review, death and re-
admission after hospital discharge: a propensity score-matched cohort s…
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psnet.ahrq.gov/issue/patient-safety-17
April 30, 2024 - Newsletter/Journal
Patient Safety.
Citation Text:
Patient Safety. Harrisburg, PA: Patient Safety Authority. ISSN 2641-4716.
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psnet.ahrq.gov/node/45461/psn-pdf
January 03, 2017 - Operating room–to-ICU patient handovers: a
multidisciplinary human-centered design approach.
January 3, 2017
Segall N, Bonifacio AS, Barbeito A, et al. Operating Room-to-ICU Patient Handovers: A Multidisciplinary
Human-Centered Design Approach. Jt Comm J Qual Patient Saf. 2016;42(9):400-14.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/46560/psn-pdf
January 24, 2019 - The hidden cost of regulation: the administrative cost of
reporting serious reportable events.
January 24, 2019
Blanchfield BB, Acharya B, Mort E. The Hidden Cost of Regulation: The Administrative Cost of Reporting
Serious Reportable Events. Jt Comm J Qual Patient Saf. 2018;44(4):212-218.
doi:10.1016/j.jcjq.2017.0…
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psnet.ahrq.gov/node/41775/psn-pdf
December 18, 2014 - Measuring adverse events and levels of harm in pediatric
inpatients with the Global Trigger Tool.
December 18, 2014
Kirkendall E, Kloppenborg E, Papp J, et al. Measuring adverse events and levels of harm in pediatric
inpatients with the Global Trigger Tool. Pediatrics. 2012;130(5):e1206-14. doi:10.1542/peds.2012-01…
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psnet.ahrq.gov/node/42211/psn-pdf
April 24, 2013 - An organizational assessment of disruptive clinician
behavior: findings and implications.
April 24, 2013
Walrath JM, Dang D, Nyberg D. An Organizational Assessment of Disruptive Clinician Behavior. J Nurs
Care Qual. 2012;28(2):110-121. doi:10.1097/ncq.0b013e318270d2ba.
https://psnet.ahrq.gov/issue/organizational-a…
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psnet.ahrq.gov/node/43448/psn-pdf
August 20, 2014 - Cost-benefit analysis of a medical emergency team in a
children's hospital.
August 20, 2014
Bonafide CP, Localio R, Song L, et al. Cost-benefit analysis of a medical emergency team in a children's
hospital. Pediatrics. 2014;134(2):235-41. doi:10.1542/peds.2014-0140.
https://psnet.ahrq.gov/issue/cost-benefit-analys…
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psnet.ahrq.gov/node/47727/psn-pdf
January 23, 2019 - Improving resident and fellow engagement in patient
safety through a graduate medical education incentive
program.
January 23, 2019
Turner DA, Bae J, Cheely G, et al. Improving Resident and Fellow Engagement in Patient Safety Through
a Graduate Medical Education Incentive Program. J Gen Intern Care. 2018;10(6):671…
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psnet.ahrq.gov/node/38712/psn-pdf
June 17, 2009 - Silence, power and communication in the operating room.
June 17, 2009
Gardezi F, Lingard LA, Espin S, et al. Silence, power and communication in the operating room. J Adv
Nurs. 2009;65(7):1390-1399. doi:10.1111/j.1365-2648.2009.04994.x.
https://psnet.ahrq.gov/issue/silence-power-and-communication-operating-room
Co…
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psnet.ahrq.gov/node/43851/psn-pdf
March 13, 2015 - Systematic review of the effectiveness of strategies to
encourage patients to remind healthcare professionals
about their hand hygiene.
March 13, 2015
Davis R, Parand A, Pinto A, et al. Systematic review of the effectiveness of strategies to encourage
patients to remind healthcare professionals about their hand hy…
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psnet.ahrq.gov/issue/empowered-patient-coalition
October 26, 2022 - Multi-use Website
Empowered Patient Coalition.
Citation Text:
Empowered Patient Coalition. Email: info@EmpoweredPatientCoalition.org.
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psnet.ahrq.gov/node/865296/psn-pdf
March 27, 2024 - National Patient Safety Goals
March 27, 2024
Shaikh U. National Patient Safety Goals. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/national-patient-safety-goals
Background
Despite the development and publication of effective and evidence-based strategies to enhance patient
safety and reduce preventable h…