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psnet.ahrq.gov/node/60000
January 01, 2021 - Patient Safety Innovations Exchange
The Patient Safety Innovations Exchange highlights important innovations that can lead to improvements in patient safety. It is based on AHRQ’s Health Care Innovations Exchange , which shares many health care innovations, including those that improve patient safety. While available …
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psnet.ahrq.gov/issue/alcoholism-and-american-healthcare-case-patient-safety-approach
March 30, 2022 - Review
Alcoholism and American healthcare: the case for a patient safety approach.
Citation Text:
Zipperer L, Ryan R, Jones B. Alcoholism and American healthcare: the case for a patient safety approach. J Patient Saf Risk Manag. 2022;27(5):201-208. doi:10.1177/25160435221117952.
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psnet.ahrq.gov/issue/multi-team-shared-expectations-tool-mt-set-exercise-improve-teamwork-across-health-care-teams
May 22, 2019 - Commentary
Multi-team shared expectations tool (MT-SET): an exercise to improve teamwork across health care teams.
Citation Text:
Marsteller JA, Rosen MA, Wyskiel R, et al. Multi-team shared expectations tool (MT-SET): an exercise to improve teamwork across health care teams. Jt Comm J Q…
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psnet.ahrq.gov/issue/reducing-risks-complex-care-transitions-rural-areas-grounded-theory
June 23, 2021 - Study
Reducing risks in complex care transitions in rural areas: a grounded theory.
Citation Text:
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:10.1080/17482…
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psnet.ahrq.gov/issue/organizational-characteristics-and-perceptions-clinical-event-notification-services
December 02, 2020 - Study
Organizational characteristics and perceptions of clinical event notification services in healthcare settings: a study of health information exchange.
Citation Text:
Wiley KK, Hilts KE, Ancker JS, et al. Organizational characteristics and perceptions of clinical event notification …
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psnet.ahrq.gov/training-catalog/asc-infection-prevention-certification-prep
January 01, 2022 - ASC Infection Prevention Certification Prep
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Organization:
Organization
Association of periOperative Registered Nurses (AORN)
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psnet.ahrq.gov/node/38729/psn-pdf
April 15, 2019 - CHPSO.
April 15, 2019
1215 K Street, Suite 800, Sacramento, CA 95814.
https://psnet.ahrq.gov/issue/chpso
This Website offers tools, a newsletter focusing on lessons learned from error reports, a set of specialized
checklists, and a detailed resource collection to support patient safety organization (PSO) efforts i…
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psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
June 02, 2021 - SPOTLIGHT CASE
Chest Pain in a Rural Hospital
Citation Text:
MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar Bi…
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psnet.ahrq.gov/issue/aftermath-adverse-event-supporting-health-care-professionals-meet-patient-expectations
May 29, 2013 - Review
Aftermath of an adverse event: supporting health care professionals to meet patient expectations through open disclosure.
Citation Text:
Manser T, Staender S. Aftermath of an adverse event: supporting health care professionals to meet patient expectations through open disclosure…
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psnet.ahrq.gov/issue/2007-guide-state-adverse-event-reporting-systems
November 29, 2009 - Book/Report
2007 Guide to State Adverse Event Reporting Systems.
Citation Text:
2007 Guide to State Adverse Event Reporting Systems. Rosenthal J, Takach M. Portland, ME: National Academy for State Health Policy; December 2007. Publication No. 2007-301.
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psnet.ahrq.gov/issue/enhancing-surgical-team-communication-sops-and-teamstepps-action
August 01, 2012 - Meeting/Conference Proceedings
Enhancing Surgical Team Communication: SOPS and TeamSTEPPS in Action.
Citation Text:
Enhancing Surgical Team Communication: SOPS and TeamSTEPPS in Action. Agency for Healthcare Research and Quality. July 25, 2024.
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…
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psnet.ahrq.gov/node/33574/psn-pdf
March 15, 2025 - Ambulatory Care Safety
March 15, 2025
Ambulatory Care Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/ambulatory-care-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Las…
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psnet.ahrq.gov/node/49844/psn-pdf
October 01, 2018 - Diffusion of Responsibility Leads to Danger
October 1, 2018
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
The Case
A 70-year-old man was sent to the emergency department (ED) from a nursing facility…
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psnet.ahrq.gov/issue/medication-reconciliation-facilitate-transitions-care-after-hospitalization
December 02, 2015 - Commentary
Medication reconciliation to facilitate transitions of care after hospitalization.
Citation Text:
Liu VC, Garwood CL. Medication reconciliation to facilitate transitions of care after hospitalization. Am J Health Syst Pharm. 2015;72(9):690-693. doi:10.2146/ajhp140133.
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psnet.ahrq.gov/node/39111/psn-pdf
November 18, 2009 - Safe Use Initiative.
November 18, 2009
Food and Drug Administration
https://psnet.ahrq.gov/issue/safe-use-initiative
This Web site supports a coordinated effort to reduce preventable medication-related errors through cross-
sector interventions.
https://psnet.ahrq.gov/issue/safe-use-initiative
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psnet.ahrq.gov/issue/approaches-improving-patient-safety-integrated-care-scoping-review
May 18, 2022 - Review
Approaches to improving patient safety in integrated care: a scoping review.
Citation Text:
Lalani M, Wytrykowski S, Hogan H. Approaches to improving patient safety in integrated care: a scoping review. BMJ Open. 2023;13(4):e067441. doi:10.1136/bmjopen-2022-067441.
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psnet.ahrq.gov/issue/toward-increased-patient-safety-electronic-communication-medication-information-between
June 23, 2021 - Study
Toward increased patient safety? Electronic communication of medication information between nurses in home health care and general practitioners.
Citation Text:
Lyngstad M, Melby L, Grimsmo A, et al. Toward Increased Patient Safety? Electronic Communication of Medication Informat…
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psnet.ahrq.gov/node/857059/psn-pdf
November 29, 2023 - The Risks of a Malpositioned Gastrostomy Tube and Poor
Communication
November 29, 2023
Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet].
2023.
https://psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
Disclosure of Relevant Financial …
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psnet.ahrq.gov/node/41768/psn-pdf
March 11, 2013 - Science and patient safety.
March 11, 2013
Vincent CA. Science and patient safety. CMAJ. 2013;185(2):110-1. doi:10.1503/cmaj.120792.
https://psnet.ahrq.gov/issue/science-and-patient-safety
This commentary recommends a coordinated scientific research effort to analyze patient safety concerns
and potential improveme…
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psnet.ahrq.gov/node/851059/psn-pdf
June 28, 2023 - Causes for medical errors in obstetrics and gynaecology.
June 28, 2023
Klemann D, Rijkx M, Mertens H, et al. Causes for medical errors in obstetrics and gynaecology. Healthcare
(Basel). 2023;11(11):1636. doi:10.3390/healthcare11111636.
https://psnet.ahrq.gov/issue/causes-medical-errors-obstetrics-and-gynaecology
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