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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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-…
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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…
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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…
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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…
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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…
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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 …
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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,…
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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…
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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…