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  1. Health Literacy Toolkit. | PSNet

    psnet.ahrq.gov/issue/health-literacy-toolkit
    February 22, 2023 - Toolkit Health Literacy Toolkit. Citation Text: Health Literacy Toolkit. Leeds, UK: Health Education England, Public Health England, NHS England and Community Health and Learning Foundation; December 11, 2017. Copy Citation Save Save to your library Print …

  2. Framework for Effective Board Governance of Health System Quality. | PSNet

    psnet.ahrq.gov/issue/framework-effective-board-governance-health-system-quality
    January 20, 2016 - Book/Report Framework for Effective Board Governance of Health System Quality. Citation Text: Framework for Effective Board Governance of Health System Quality. Daley Ullem E, Gandhi TK, Mate K, et al. IHI White Paper. Boston, MA: Institute for Healthcare Improvement; 2018. Copy Citati…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867804/psn-pdf
    February 26, 2025 - Are We Safer Today? February 26, 2025 Bates DW, Lee M, Mossburg SE. Are We Safer Today? PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/are-we-safer-today In the 1999 report, To Err Is Human: Building a Safer Health System, the Institute of Medicine (now the National Academy of Medicine) drew on two lar…

  4. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
    May 01, 2009 - Spotlight Case July 2008 Spotlight Case Delirium or Dementia? Source and Credits This presentation is based on the May 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: James L. Rudolph, MD, SM Editor, AHRQ WebM&M: Robert Wachter, MD Sp…

  5. Getting to the Root of the Matter | PSNet

    psnet.ahrq.gov/web-mm/getting-root-matter
    September 01, 2005 - SPOTLIGHT CASE Getting to the Root of the Matter Citation Text: Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Schola…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49759/psn-pdf
    May 01, 2016 - Falling Through the Crack (in the Bedrails) May 1, 2016 Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/falling-through-crack-bedrails Case Objectives Review the epidemiology of patient falls and associated injuries in the hospital set…

  7. Pathology and patient safety: the critical role of pathology informatics in error reduction and quality initiatives. | PSNet

    psnet.ahrq.gov/issue/pathology-and-patient-safety-critical-role-pathology-informatics-error-reduction-and-quality
    July 20, 2009 - Review Pathology and patient safety: the critical role of pathology informatics in error reduction and quality initiatives. Citation Text: Becich MJ, Gilbertson JR, Gupta D, et al. Pathology and patient safety: the critical role of pathology informatics in error reduction and quality i…

  8. Creating a culture of safety in the emergency department: the value of teamwork training. | PSNet

    psnet.ahrq.gov/issue/creating-culture-safety-emergency-department-value-teamwork-training
    October 14, 2020 - Study Creating a culture of safety in the emergency department: the value of teamwork training. Citation Text: Jones F, Podila P, Powers C. Creating a culture of safety in the emergency department: the value of teamwork training. J Nurs Adm. 2013;43(4):194-200. doi:10.1097/NNA.0b013e318…

  9. An organizational framework to reduce professional burnout and bring back joy in practice. | PSNet

    psnet.ahrq.gov/issue/organizational-framework-reduce-professional-burnout-and-bring-back-joy-practice
    February 03, 2016 - Commentary An organizational framework to reduce professional burnout and bring back joy in practice. Citation Text: Swensen S, Shanafelt TD. An Organizational Framework to Reduce Professional Burnout and Bring Back Joy in Practice. Jt Comm J Qual Patient Saf. 2017;43(6):308-313. doi:10.…

  10. Implementation of the SBAR communication technique in a tertiary center. | PSNet

    psnet.ahrq.gov/issue/implementation-sbar-communication-technique-tertiary-center
    March 27, 2019 - Commentary Implementation of the SBAR communication technique in a tertiary center. Citation Text: Woodhall LJ, Vertacnik L, McLaughlin M. Implementation of the SBAR Communication Technique in a Tertiary Center. J Emerg Nurs. 2008;34(4):314-317. doi:10.1016/j.jen.2007.07.007. Copy Ci…

  11. Nurses' sleep, work hours, and patient care quality, and safety | PSNet

    psnet.ahrq.gov/issue/nurses-sleep-work-hours-and-patient-care-quality-and-safety
    April 23, 2012 - Study Nurses' sleep, work hours, and patient care quality, and safety Citation Text: Nurses' sleep, work hours, and patient care quality, and safety Stimpfel AW, Fatehi F, Kovner C. Sleep Health. 2020;6(3):314-320. Copy Citation Save Save to your library P…

  12. Sample to sample carryover: a source of analytical laboratory error and its relevance to integrated clinical chemistry/immunoassay systems. | PSNet

    psnet.ahrq.gov/issue/sample-sample-carryover-source-analytical-laboratory-error-and-its-relevance-integrated
    January 12, 2022 - Study Sample to sample carryover: a source of analytical laboratory error and its relevance to integrated clinical chemistry/immunoassay systems. Citation Text: Armbruster DA, Alexander DB. Sample to sample carryover: a source of analytical laboratory error and its relevance to integra…

  13. For 4 days, the hospital thought he had just pneumonia. It was coronavirus. | PSNet

    psnet.ahrq.gov/issue/4-days-hospital-thought-he-had-just-pneumonia-it-was-coronavirus
    November 29, 2023 - Newspaper/Magazine Article For 4 days, the hospital thought he had just pneumonia. It was coronavirus. Citation Text: Goldstein J, Salcedo A. For 4 days, the hospital thought he had just pneumonia. It was coronavirus. New York Times. 2020;March 10. Copy Citation Format: Goo…

  14. Hospital safety climate surveys: measurement issues. | PSNet

    psnet.ahrq.gov/issue/hospital-safety-climate-surveys-measurement-issues
    December 16, 2009 - Review Hospital safety climate surveys: measurement issues. Citation Text: Jackson J, Sarac C, Flin R. Hospital safety climate surveys: measurement issues. Curr Opin Crit Care. 2010;16(6):632-8. doi:10.1097/MCC.0b013e32833f0ee6. Copy Citation Format: DOI Google Scholar Pu…

  15. Measuring team performance in healthcare: review of research and implications for patient safety. | PSNet

    psnet.ahrq.gov/issue/measuring-team-performance-healthcare-review-research-and-implications-patient-safety
    November 20, 2019 - Review Measuring team performance in healthcare: review of research and implications for patient safety. Citation Text: Jeffcott SA, Mackenzie CF. Measuring team performance in healthcare: review of research and implications for patient safety. J Crit Care. 2008;23(2):188-96. doi:10.10…

  16. Human factors and error prevention in emergency medicine. | PSNet

    psnet.ahrq.gov/issue/human-factors-and-error-prevention-emergency-medicine
    October 03, 2011 - Commentary Human factors and error prevention in emergency medicine. Citation Text: Bleetman A, Sanusi S, Dale T, et al. Human factors and error prevention in emergency medicine. Emerg Med J. 2012;29(5):389-93. doi:10.1136/emj.2010.107698. Copy Citation Format: DOI Google…

  17. The disclosure of unanticipated outcomes of care and medical errors: what does this mean for anesthesiologists? | PSNet

    psnet.ahrq.gov/issue/disclosure-unanticipated-outcomes-care-and-medical-errors-what-does-mean-anesthesiologists
    August 21, 2024 - Review The disclosure of unanticipated outcomes of care and medical errors: what does this mean for anesthesiologists? Citation Text: Souter KJ, Gallagher TH. The Disclosure of Unanticipated Outcomes of Care and Medical Errors. Anesth Analg. 2011;114(3):615-621. doi:10.1213/ane.0b013e3…

  18. A review of educational philosophies as applied to radiation safety training at medical institutions. | PSNet

    psnet.ahrq.gov/issue/review-educational-philosophies-applied-radiation-safety-training-medical-institutions
    May 31, 2017 - Commentary A review of educational philosophies as applied to radiation safety training at medical institutions. Citation Text: Dauer LT, St Germain J. A review of educational philosophies as applied to radiation safety training at medical institutions. Health Phys. 2006;90(5 Suppl):S6…

  19. A next act for patient safety. | PSNet

    psnet.ahrq.gov/issue/next-act-patient-safety
    September 03, 2011 - Commentary A next act for patient safety. Citation Text: Viola AF, Kallem C, Bronnert J. A next act for patient safety. J AHIMA. 2009;80(4):30-5; quiz 37-8. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  20. Diagnostic error: untapped potential for improving patient safety? | PSNet

    psnet.ahrq.gov/issue/diagnostic-error-untapped-potential-improving-patient-safety
    March 02, 2016 - Commentary Diagnostic error: untapped potential for improving patient safety? Citation Text: Groszkruger D. Diagnostic error: untapped potential for improving patient safety? J Healthc Risk Manag. 2014;34(1):38-43. doi:10.1002/jhrm.21149. Copy Citation Format: DOI Google Sc…
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