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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43009/psn-pdf
    January 07, 2015 - Improving the Emergency Department Discharge Process. January 7, 2015 Boonyasai RT, Ijagbemi OM, Pham JC, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. 14(15)-0067-EF. https://psnet.ahrq.gov/issue/improving-emergency-department-discharge-process This report a…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43100/psn-pdf
    April 02, 2014 - Taking National Action to Prevent and Eliminate Healthcare-Associated Infections. April 2, 2014 Kahn KL, Battles JB, eds. Med Care. 2014;52:i-ii,s1-s100.  https://psnet.ahrq.gov/issue/taking-national-action-prevent-and-eliminate-healthcare-associated-infections This special issue explores a national initiativ…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837044/psn-pdf
    May 04, 2022 - How Discrimination in Health Care Affects Older Americans, and What Health Systems and Providers Can Do. May 4, 2022 Doty MM, Horstman C, Shah A et al. Issue Brief. New York, NY: Commonwealth Fund: April 2022. https://psnet.ahrq.gov/issue/how-discrimination-health-care-affects-older-americans-and-what-health- sys…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850170/psn-pdf
    June 07, 2023 - A scoping review of distributed cognition in acute care clinical decision-making. June 7, 2023 Wilson E, Daniel M, Rao A, et al. A scoping review of distributed cognition in acute care clinical decision- making. Diagnosis (Berl). 2023;10(2):68-88. doi:10.1515/dx-2022-0095. https://psnet.ahrq.gov/issue/scoping-revi…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847054/psn-pdf
    April 05, 2023 - Patient generated research priorities to improve diagnostic safety: a systematic prioritization exercise. April 5, 2023 Zwaan L, Smith KM, Giardina TD, et al. Patient generated research priorities to improve diagnostic safety: a systematic prioritization exercise. Patient Educ Couns. 2023;110:107650. doi:10.1016/j…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836760/psn-pdf
    March 16, 2022 - Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020. March 16, 2022 Washington, DC: VA Office of the Inspector General;  February 17, 2022. Report No. 21-01506-76. https://psnet.ahrq.gov/issue/comprehensive-healthcare-i…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74086/psn-pdf
    November 17, 2021 - Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration. November 17, 2021 Soncrant C, Mills PD, Pendley Louis RP, et al. Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration. J Patien…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845353/psn-pdf
    March 01, 2023 - Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California. March 1, 2023 Washington, DC: VA Office of the Inspector General; February 2, 2023. Report no. 22-01363-52. https://psnet.ahrq.gov/issue/inadequate-outpatient-mental-health-triage-and…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60636/psn-pdf
    July 01, 2020 - Measuring the impact of medication-related interventions on 30-day readmission rates in a skilled nursing facility. July 1, 2020 Amin PB, Bradford CD, Rizos AL, et al. Measuring the Impact of Medication-Related Interventions on 30- Day Readmission Rates in a Skilled Nursing Facility. J Pharm Pract. 2020;33(3):306-3…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851648/psn-pdf
    July 26, 2023 - Perspectives about racism and patient-clinician communication among black adults with serious illness. July 26, 2023 Brown CE, Marshall AR, Snyder CR, et al. Perspectives about racism and patient-clinician communication among black adults with serious illness. JAMA Netw Open. 2023;6(7):e2321746. doi:10.1001/jamane…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853068/psn-pdf
    August 30, 2023 - Healthcare fragmentation, multimorbidity, potentially inappropriate medication, and mortality: a Danish nationwide cohort study. August 30, 2023 Prior A, Vestergaard CH, Vedsted P, et al. Healthcare fragmentation, multimorbidity, potentially inappropriate medication, and mortality: a Danish nationwide cohort study…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74191/psn-pdf
    December 15, 2021 - Race differences in reported "near miss" patient safety events in health care system high reliability organizations. December 15, 2021 Thomas AD, Pandit C, Krevat S. Race differences in reported "near miss" patient safety events in health care system high reliability organizations. J Patient Saf. 2021;17(8):e1605-…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50651/psn-pdf
    November 13, 2019 - How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis. November 13, 2019 Schmutz JB, Meier LL, Manser T. How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic rev…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50913/psn-pdf
    February 19, 2020 - "Disruptive behavior" in the operating room: A prospective observational study of triggers and effects of tense communication episodes in surgical teams. February 19, 2020 Keller S, Tschan F, Semmer NK, et al. “Disruptive behavior” in the operating room: A prospective observational study of triggers and effects of…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36226/psn-pdf
    August 30, 2006 - Framework for a High Performance Health System for the United States. August 30, 2006 Mongan JJ. New York, NY; The Commonwealth Fund: 2006. https://psnet.ahrq.gov/issue/framework-high-performance-health-system-united-states This report calls for providing "safe, well-coordinated, accessible, and efficient" care th…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47132/psn-pdf
    June 28, 2018 - National Steering Committee for Patient Safety. June 28, 2018 Agency for Healthcare Research and Quality and the Institute for Healthcare Improvement. https://psnet.ahrq.gov/issue/national-steering-committee-patient-safety Preventable patient harm is a global public health concern. This announcement highlights a ne…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45466/psn-pdf
    September 07, 2016 - Building a highway to quality health care. September 7, 2016 Watson S, Pronovost P. Building a Highway to Quality Health Care. J Patient Saf. 2016;12(3):165-6. doi:10.1097/PTS.0000000000000074. https://psnet.ahrq.gov/issue/building-highway-quality-health-care Substantial progress has been made in improving health …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47647/psn-pdf
    January 23, 2019 - Patient Safety: Global Action on Patient Safety. January 23, 2019 Executive Board EB144/29 144th session. Geneva, Switzerland: World Health Organization; December 12, 2018. https://psnet.ahrq.gov/issue/patient-safety-global-action-patient-safety This guidance summarizes the current status of global patient safety,…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38125/psn-pdf
    January 11, 2017 - 2008 John M. Eisenberg Patient Safety and Quality Awards. January 11, 2017 Jt Comm J Qual Patient Saf. 2008;34(12):691-712. https://psnet.ahrq.gov/issue/2008-john-m-eisenberg-patient-safety-and-quality-awards The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60242/psn-pdf
    March 01, 2021 - Team-Developed Care Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes and Reduced Acute Care Utilization in Low-Income Seniors and other High-Risk Populations Originally published on June 12, 2020 Last updated on January 11, 2021 https://psnet.ahrq.gov/innovatio…

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