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psnet.ahrq.gov/node/61057/psn-pdf
October 28, 2020 - Improving Diagnostic Quality and Safety/Reducing
Diagnostic Error: Measurement Considerations. Final
Report
October 28, 2020
Washington DC; National Quality Forum: October 6, 2020.
https://psnet.ahrq.gov/issue/improving-diagnostic-quality-and-safetyreducing-diagnostic-error-
measurement-considerations
With input…
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digital.ahrq.gov/principal-investigator/matthews-karen
January 01, 2023 - Matthews, Karen
The Bettering Lives Utilizing Electronic Systems (BLUES) Project: Improving Diabetes Outcomes in Mississippi with Health Information Technology - Final Report
Citation
Fox K. The Bettering Lives Utilizing Electronic Systems (BLUES) Project: Improving Diabetes O…
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psnet.ahrq.gov/node/36549/psn-pdf
March 21, 2017 - Patients' concerns about medical errors during
hospitalization.
March 21, 2017
Burroughs TE, Waterman AD, Gallagher TH, et al. Patients' concerns about medical errors during
hospitalization. Jt Comm J Qual Patient Saf. 2007;33(1):5-14.
https://psnet.ahrq.gov/issue/patients-concerns-about-medical-errors-during-hosp…
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psnet.ahrq.gov/node/42439/psn-pdf
November 23, 2016 - Guide to Patient and Family Engagement in Hospital
Quality and Safety.
November 23, 2016
Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
https://psnet.ahrq.gov/issue/guide-patient-and-family-engagement-hospital-quality-and-safety
Studies have shown that a surprisingly large proportion of hosp…
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psnet.ahrq.gov/node/60576/psn-pdf
June 10, 2020 - Patient safety over power hierarchy: a scoping review of
healthcare professionals' speaking-up skills training.
June 10, 2020
Kim S, Appelbaum NP, Baker N, et al. Patient Safety Over Power Hierarchy: A Scoping Review of
Healthcare Professionals' Speaking-up Skills Training. J Healthc Qual. 2020;42(5):249-263.
doi:…
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psnet.ahrq.gov/node/73962/psn-pdf
October 13, 2021 - Building a program of expanded peer support for the
entire health care team: no one left behind.
October 13, 2021
Klatt TE, Sachs JF, Huang C-C, et al. Building a program of expanded peer support for the entire health
care team: no one left behind. Jt Comm J Qual Patient Saf. 2021;47(12):759-767.
doi:10.1016/j.jcj…
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psnet.ahrq.gov/node/73425/psn-pdf
June 23, 2021 - A qualitative study of what care workers do to provide
patient safety at home through telecare.
June 23, 2021
Stokke R, Melby L, Isaksen J, et al. A qualitative study of what care workers do to provide patient safety at
home through telecare. BMC Health Serv Res. 2021;21(1):553. doi:10.1186/s12913-021-06556-4.
htt…
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psnet.ahrq.gov/node/60906/psn-pdf
August 18, 2021 - Global Patient Safety Action Plan 2021-2030: Towards
Eliminating Avoidable Harm in Health Care.
August 18, 2021
Geneva, Switzerland: World Health Organization; 2021. ISBN: 9789240032705.
https://psnet.ahrq.gov/issue/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-
harm-health-care
The Wo…
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psnet.ahrq.gov/node/865968/psn-pdf
May 29, 2024 - A strategic solution to preventing the harm associated
with ambulance handover delays.
May 29, 2024
Evans C, Da’Costa A. A strategic solution to preventing the harm associated with ambulance handover
delays. Emerg Nurse. 2024;32(6):32(6):15-20. doi:10.7748/en.2024.e2199.
https://psnet.ahrq.gov/issue/strategic-solu…
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psnet.ahrq.gov/node/838186/psn-pdf
September 28, 2022 - Understanding teamwork in rapidly deployed
interprofessional teams in intensive and acute care: a
systematic review of reviews.
September 28, 2022
Schilling S, Armaou M, Morrison Z, et al. Understanding teamwork in rapidly deployed interprofessional
teams in intensive and acute care: a systematic review of reviews…
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psnet.ahrq.gov/node/841152/psn-pdf
December 07, 2022 - Interprofessional clinical event debriefing-does it make a
difference? Attitudes of emergency department care
providers to INFO clinical event debriefings.
December 7, 2022
Rose SC, Ashari NA, Davies JM, et al. Interprofessional clinical event debriefing-does it make a difference?
Attitudes of emergency department…
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psnet.ahrq.gov/node/838247/psn-pdf
October 05, 2022 - Recommendations for the safety of hospitalised patients
in the context of the COVID-19 pandemic: a scoping
review.
October 5, 2022
Martins MS, Lourenção DC de A, Pimentel RR da S, et al. Recommendations for the safety of hospitalised
patients in the context of the COVID-19 pandemic: a scoping review. BMJ Open. 202…
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psnet.ahrq.gov/node/867596/psn-pdf
January 22, 2025 - Creation of root cause analysis and action (RCA2)
standard work by a multidisciplinary team to prevent
harm, reduce bias, and improve safety culture.
January 22, 2025
Musheno D, Harnish M, Roberts J, et al. Creation of root cause analysis and action (RCA2) standard work
by a multidisciplinary team to prevent harm,…
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psnet.ahrq.gov/node/867523/psn-pdf
January 15, 2025 - How do we know when we have done enough? Ensuring
sufficient patient notification efforts after a large-scale
adverse event.
January 15, 2025
Alfandre D, Foglia MB, Holodniy M, et al. How do we know when we have done enough? Ensuring
sufficient patient notification efforts after a large-scale adverse event. Jt Com…
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psnet.ahrq.gov/node/867445/psn-pdf
January 08, 2025 - Using human factors methods to mitigate bias in artificial
intelligence-based clinical decision support.
January 8, 2025
Militello LG, Diiulio J, Wilson DL, et al. Using human factors methods to mitigate bias in artificial
intelligence-based clinical decision support. J Am Med Inform Assoc. 2025;32(2):398-403.
doi…
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psnet.ahrq.gov/node/73513/psn-pdf
July 21, 2021 - Analysis of suicides reported as adverse events in
psychiatry resulted in nine quality improvement
initiatives.
July 21, 2021
Mackenhauer J, Winsløv J-H, Holmskov J, et al. Analysis of suicides reported as adverse events in
psychiatry resulted in nine quality improvement initiatives. Crisis. 2021;43(4):307-314. do…
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psnet.ahrq.gov/node/60646/psn-pdf
July 01, 2020 - An integrative total worker health framework for keeping
workers safe and healthy during the COVID-19 pandemic.
July 1, 2020
Dennerlein JT, Burke L, Sabbath EL, et al. An Integrative Total Worker Health Framework for Keeping
Workers Safe and Healthy During the COVID-19 Pandemic. Hum Factors. 2020;62(5):689–696.
do…
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psnet.ahrq.gov/node/44774/psn-pdf
June 21, 2016 - Association of safety culture with surgical site infection
outcomes.
June 21, 2016
Fan CJ, Pawlik TM, Daniels T, et al. Association of safety culture with surgical site infection outcomes. J
Am Coll Surg. 2016;222(2):122-128. doi:10.1016/j.jamcollsurg.2015.11.008.
https://psnet.ahrq.gov/issue/association-safety-cu…
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psnet.ahrq.gov/node/764404/psn-pdf
March 02, 2022 - Systemic safety inequities for people with learning
disabilities: a qualitative integrative analysis of the
experiences of English health and social care for people
with learning disabilities, their families and carers.
March 2, 2022
Ramsey L, Albutt AK, Perfetto K, et al. Systemic safety inequities for people wit…
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psnet.ahrq.gov/node/865678/psn-pdf
April 24, 2024 - Enhancing implementation of the I-PASS handoff tool
using a provider handoff task force at a Comprehensive
Cancer Center.
April 24, 2024
Franco Vega MC, Ait Aiss M, George M, et al. Enhancing implementation of the I-PASS handoff tool using
a provider handoff task force at a Comprehensive Cancer Center. Jt Comm J Q…