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psnet.ahrq.gov/node/34100/psn-pdf
February 09, 2011 - Safety of patients isolated for infection control.
February 9, 2011
Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infection control. JAMA.
2003;290(14):1899-1905.
https://psnet.ahrq.gov/issue/safety-patients-isolated-infection-control
This study discovered that patients isolated for coloniza…
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psnet.ahrq.gov/node/72534/psn-pdf
December 02, 2020 - Patients' perceptions of safety in emergency medical
services: an interview study.
December 2, 2020
Venesoja A, Castrén M, Tella S, et al. Patients’ perceptions of safety in emergency medical services: an
interview study. BMJ Open. 2020;10(10):e037488. doi:10.1136/bmjopen-2020-037488.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/846451/psn-pdf
March 22, 2023 - Reducing risks in complex care transitions in rural areas:
a grounded theory.
March 22, 2023
Winqvist I, Näppä U, Rönning H, et al. Reducing risks in complex care transitions in rural areas: a
grounded theory. Int J Qual Stud Health Well-being. 2023;18(1):2185964.
doi:10.1080/17482631.2023.2185964.
https://psnet.…
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psnet.ahrq.gov/node/837042/psn-pdf
April 04, 2022 - Leadership Response to a Sentinel Event: Respectful,
Effective Crisis Management.
April 4, 2022
Institute for Healthcare Improvement.
https://psnet.ahrq.gov/issue/leadership-response-sentinel-event-respectful-effective-crisis-management
Crisis management skills are valuable at both the organizational and clinical …
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psnet.ahrq.gov/node/43505/psn-pdf
April 25, 2016 - Hospitals often ignore policies on using qualified medical
interpreters.
April 25, 2016
Rice S. Language liabilities. To avoid errors, hospitals urged to use qualified interpreters for patients with
limited English. Modern healthcare. 2014;44(35):16-8, 20.
https://psnet.ahrq.gov/issue/hospitals-often-ignore-polici…
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psnet.ahrq.gov/node/42991/psn-pdf
March 12, 2014 - Medication errors in hospitalised children.
March 12, 2014
Manias E, Kinney S, Cranswick N, et al. Medication errors in hospitalised children. J Paediatr Child Health.
2014;50(1):71-7. doi:10.1111/jpc.12412.
https://psnet.ahrq.gov/issue/medication-errors-hospitalised-children
Consistent with findings from prior st…
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psnet.ahrq.gov/node/42314/psn-pdf
May 19, 2014 - "Apologies" for pathologists: why, when, and how to say
"sorry" after committing a medical error.
May 19, 2014
Dewar R, Parkash V, Forrow L, et al. "Apologies" from pathologists: why, when, and how to say "sorry"
after committing a medical error. Int J Surg Pathol. 2014;22(3):242-6. doi:10.1177/1066896913487986.
h…
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psnet.ahrq.gov/node/60567/psn-pdf
June 03, 2020 - Keeping Nursing Home Residents and Staff Safe in the
Era of COVID-19.
June 3, 2020
National Academy of Medicine. April-June 2020.
https://psnet.ahrq.gov/issue/keeping-nursing-home-residents-and-staff-safe-era-covid-19
Nursing homes are care environments that are particularly challenged by the COVID-19 pandemic. Th…
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psnet.ahrq.gov/node/48082/psn-pdf
June 19, 2019 - Unintended discontinuation of medication following
hospitalisation: a retrospective cohort study.
June 19, 2019
Redmond P, McDowell R, Grimes TC, et al. Unintended discontinuation of medication following
hospitalisation: a retrospective cohort study. BMJ Open. 2019;9(6):e024747. doi:10.1136/bmjopen-2018-
024747.
…
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psnet.ahrq.gov/node/41511/psn-pdf
June 03, 2013 - A multicentre observational study to evaluate a new tool
to assess emergency physicians' non-technical skills.
June 3, 2013
Flowerdew L, Gaunt A, Spedding J, et al. A multicentre observational study to evaluate a new tool to
assess emergency physicians' non-technical skills. Emerg Med J. 2013;30(6):437-43.
doi:10.…
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psnet.ahrq.gov/node/34770/psn-pdf
April 17, 2017 - Clinical Risk Management. Enhancing Patient Safety. 2nd
ed.
April 17, 2017
Vincent CA, ed. London, UK: BMJ Books; 2001. ISBN: 9780727913920.
https://psnet.ahrq.gov/issue/clinical-risk-management-enhancing-patient-safety-2nd-ed
Vincent has updated his text on risk management, infusing it with concepts directly rela…
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psnet.ahrq.gov/node/41873/psn-pdf
November 28, 2012 - A new tool to give hospitalists feedback to improve
interprofessional teamwork and advance patient care.
November 28, 2012
Chesluk BJ, Bernabeo E, Hess B, et al. A new tool to give hospitalists feedback to improve
interprofessional teamwork and advance patient care. Health Aff (Millwood). 2012;31(11):2485-2492.
do…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/worksheet.docx
May 01, 2017 - AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership
AHRQ Safety Program for Perinatal Care
Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership
Purpose: To enhance communication and shared problem solving between clinic…
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psnet.ahrq.gov/node/60796/psn-pdf
August 12, 2020 - The challenges and opportunities for shared decision
making highlighted by COVID-19.
August 12, 2020
Abrams EM, Shaker M, Oppenheimer J, et al. The challenges and opportunities for shared decision making
highlighted by COVID-19. J Allergy Clin Immunol Pract. 2020;8(8):2474-2480.e1.
doi:10.1016/j.jaip.2020.07.003.
…
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www.ahrq.gov/action-alliance/webinars/psychological-safety.html
March 01, 2025 - National Action Alliance Webinar: Establishing Psychological Safety for Healthcare Workers
Creating and Maintaining a Culture of Safety Series (Session 1)
This webinar was the first of a three-part series on Safety Culture in Healthcare. On February 18, 2025, experts shared how leadership rounding with staff …
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psnet.ahrq.gov/node/47260/psn-pdf
August 08, 2018 - Building the Case for Health Literacy: Proceedings of a
Workshop.
August 8, 2018
National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press;
2018. ISBN: 9780309474290.
https://psnet.ahrq.gov/issue/building-case-health-literacy-proceedings-workshop
Health literacy affects p…
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www.ahrq.gov/hai/tools/mvp/technical-bundles.html
March 01, 2017 - Technical Bundles Module
This module provides evidence-based recommendations, literature reviews, sample protocols, and other resources to help the team address the following topics:
Daily Care Processes
Early Mobility
Low Tidal Volume Ventilation
Overview of the AHRQ Safety Program for Mechanically…
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digital.ahrq.gov/sites/default/files/docs/page/2006McColm_051111comp.pdf
June 16, 2021 - Health Information Technology & Patient Safety
Health Information Technology &
Patient Safety
Denni McColm, CIO, Citizens Memorial Healthcare
Fast Facts
• 74 acute beds
• Level III trauma center
• 5 LTC facilities
• Residential care & independent living
• Home care/hospice
• 16 physician offices
• 1,550 e…
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psnet.ahrq.gov/node/38970/psn-pdf
July 05, 2013 - Joint Commission Center for Transforming Healthcare.
July 5, 2013
Joint Commission.
https://psnet.ahrq.gov/issue/joint-commission-center-transforming-healthcare
The Joint Commission has traditionally focused on accreditation of health care organizations and, through
its Joint Commission Resources arm, on quality i…
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psnet.ahrq.gov/node/46240/psn-pdf
June 21, 2017 - Implementation of a modified bedside handoff for a
postpartum unit.
June 21, 2017
Wollenhaup CA, Stevenson EL, Thompson J, et al. Implementation of a Modified Bedside Handoff for a
Postpartum Unit. J Nurs Admin. 2017;47(6):320-326. doi:10.1097/NNA.0000000000000487.
https://psnet.ahrq.gov/issue/implementation-modif…