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psnet.ahrq.gov/node/43970/psn-pdf
May 19, 2015 - Organisational reporting and learning systems:
innovating inside and outside of the box.
May 19, 2015
Sujan M, Furniss D. Organisational reporting and learning systems: Innovating inside and outside of the
box. Clin Risk. 2015;21(1):7-12. doi:10.1177/1356262215574203.
https://psnet.ahrq.gov/issue/organisational-re…
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psnet.ahrq.gov/node/35990/psn-pdf
September 17, 2010 - Misunderstanding of prescription drug warning labels
among patients with low literacy.
September 17, 2010
Wolf MS, Davis TC, Tilson HH, et al. Misunderstanding of prescription drug warning labels among patients
with low literacy. Am J Health Syst Pharm. 2006;63(11):1048-55.
https://psnet.ahrq.gov/issue/misundersta…
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psnet.ahrq.gov/node/45634/psn-pdf
January 11, 2017 - Operating room traffic as a modifiable risk factor for
surgical site infection.
January 11, 2017
Wanta BT, Glasgow AE, Habermann EB, et al. Operating Room Traffic as a Modifiable Risk Factor for
Surgical Site Infection. Surg Infect (Larchmt). 2016;17(6):755-760.
https://psnet.ahrq.gov/issue/operating-room-traffic-…
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psnet.ahrq.gov/node/34812/psn-pdf
March 05, 2008 - The critical incident technique.
March 5, 2008
FLANAGAN JC. The critical incident technique. Psychol Bull. 1954;51(4):327-358.
https://psnet.ahrq.gov/issue/critical-incident-technique
This review details the background of a methodology aimed to record specific behaviors, rather than
opinions or estimates, in evalu…
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psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - Getting the Diagnosis Both Right and Wrong
Citation Text:
Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3…
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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/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/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/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/73483/psn-pdf
July 14, 2021 - Critical care nurses’ physical and mental health, worksite
wellness support, and medical errors.
July 14, 2021
Melnyk BM, Tan A, Hsieh AP, et al. Critical Care Nurses’ Physical and Mental Health, Worksite Wellness
Support, and Medical Errors. Am J Crit Care. 2021;30(3):176-184. doi:10.4037/ajcc2021301.
https://psn…
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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/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - AHRQ PSNet Webinar
AHRQ PSNet Webinar
Making Healthcare Safer (MHS) IV:
Rapid Response Systems and Opioid Stewardship
February 10, 2025
Agenda
2
• Logistics
• Introduction to the Making Healthcare Safer (MHS) IV Reports
• Report 1 – Rapid Response Systems
► Discussion
► PSNet Resources
• Report 2 – Opioi…
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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/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/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/42503/psn-pdf
September 18, 2013 - The patient is in: patient involvement strategies for
diagnostic error mitigation.
September 18, 2013
McDonald KM, Bryce CL, Graber ML. The patient is in: patient involvement strategies for diagnostic error
mitigation. BMJ Qual Saf. 2013;22 Suppl 2:ii33-ii39. doi:10.1136/bmjqs-2012-001623.
https://psnet.ahrq.gov/i…
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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…