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psnet.ahrq.gov/node/855419/psn-pdf
November 15, 2023 - Using stakeholder intervention refinement teams to
develop approaches for real-time integration of patient-
reported safety information during older adults’ hospital-
to-home-health care transitions.
November 15, 2023
Arbaje AI, Greyson S, Keita Fakeye M, et al. Using stakeholder intervention refinement teams to d…
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psnet.ahrq.gov/node/862137/psn-pdf
February 07, 2024 - What do parents think about the quality and safety of care
provided by hospitals to children and young people with
an intellectual disability? A qualitative study using
thematic analysis.
February 7, 2024
Ong N, Lucien A, Long JC, et al. What do parents think about the quality and safety of care provided by
hospi…
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psnet.ahrq.gov/node/33694/psn-pdf
April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA
April 1, 2010
In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
Editor's note: Janet M. Corrigan, PhD, MBA, is president and CEO of the National Quality Forum (NQF), a
priva…
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psnet.ahrq.gov/node/35112/psn-pdf
June 22, 2009 - Medication safety in older adults: home-based practice
patterns.
June 22, 2009
Metlay JP, Cohen A, Polsky D, et al. Medication safety in older adults: home-based practice patterns. J Am
Geriatr Soc. 2005;53(6):976-982.
https://psnet.ahrq.gov/issue/medication-safety-older-adults-home-based-practice-patterns
This s…
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psnet.ahrq.gov/node/46217/psn-pdf
January 30, 2018 - Safer and more appropriate opioid prescribing: a large
healthcare system's comprehensive approach.
January 30, 2018
Losby JL, Hyatt JD, Kanter MH, et al. Safer and more appropriate opioid prescribing: a large healthcare
system's comprehensive approach. J Eval Clin Pract. 2017;23(6):1173-1179. doi:10.1111/jep.12756.…
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psnet.ahrq.gov/node/47065/psn-pdf
June 20, 2018 - The complexity, diversity, and science of primary care
teams.
June 20, 2018
Fiscella K, McDaniel SH. The complexity, diversity, and science of primary care teams. Amer Psychol.
2018;73(4):451-467. doi:10.1037/amp0000244.
https://psnet.ahrq.gov/issue/complexity-diversity-and-science-primary-care-teams
Teamwork is …
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psnet.ahrq.gov/node/47205/psn-pdf
July 25, 2018 - Teamwork and Teamwork Training in Healthcare.
July 25, 2018
Teamwork and Teamwork Training in Health care: An Integration and a Path Forward. Buljac-Samardzic M,
Dekker-van Doorn C, Maynard MT, eds. Group Org Manag. 2018;43(3):351-527.
doi:10.1177/1059601118774669.
https://psnet.ahrq.gov/issue/teamwork-and-teamwor…
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psnet.ahrq.gov/node/36529/psn-pdf
August 09, 2011 - 5 Million Lives Campaign.
August 9, 2011
Institute for Healthcare Improvement; IHI
https://psnet.ahrq.gov/issue/5-million-lives-campaign
The Institute for Healthcare Improvement's 100,000 Lives Campaign successfully engaged more than
3,000 US hospitals in a coordinated effort to reduce preventable inpatient deaths…
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psnet.ahrq.gov/node/46912/psn-pdf
March 28, 2018 - Ignoring the Alarms: How NHS Eating Disorder Services
Are Failing Patients.
March 28, 2018
London, UK: Parliamentary and Health Service Ombudsman; 2017. ISBN: 9781528601344.
https://psnet.ahrq.gov/issue/ignoring-alarms-how-nhs-eating-disorder-services-are-failing-patients
Patients with mental health conditions fac…
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psnet.ahrq.gov/node/44901/psn-pdf
March 30, 2016 - Medication safety pharmacy technician in a large, tertiary
care, community hospital.
March 30, 2016
Brown KN, Bergsbaken J, Reichard JS. Medication safety pharmacy technician in a large, tertiary care,
community hospital. Am J Health Syst Pharm. 2016;73(4):188-191. doi:10.2146/ajhp150098.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/33935/psn-pdf
February 05, 2018 - The incidence and severity of adverse events affecting
patients after discharge from the hospital.
February 5, 2018
Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients
after discharge from the hospital. Ann Intern Med. 2003;138(3):161-7.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/46409/psn-pdf
November 08, 2017 - 'No one is coming': hospice patients abandoned at
death's door.
November 8, 2017
Aleccia J; Bailey M.
https://psnet.ahrq.gov/issue/no-one-coming-hospice-patients-abandoned-deaths-door
Patient safety in ambulatory hospice care is ill defined. Reporting on safety concerns associated with
hospice care, including poo…
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psnet.ahrq.gov/node/33925/psn-pdf
December 18, 2008 - Drug-related morbidity and mortality and the economic
impact of pharmaceutical care.
December 18, 2008
Johnson JA, Bootman JL. Drug-related morbidity and mortality and the economic impact of pharmaceutical
care. Am J Health Syst Pharm. 1997;54(5):554-8.
https://psnet.ahrq.gov/issue/drug-related-morbidity-and-morta…
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psnet.ahrq.gov/node/44868/psn-pdf
June 17, 2016 - Patient safety and the problem of many hands.
June 17, 2016
Dixon-Woods M, Pronovost P. Patient safety and the problem of many hands. BMJ Qual Saf.
2016;25(7):485-488. doi:10.1136/bmjqs-2016-005232.
https://psnet.ahrq.gov/issue/patient-safety-and-problem-many-hands
Although individual and organizational accountabi…
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psnet.ahrq.gov/node/37342/psn-pdf
December 23, 2012 - Toward higher-performance health systems: adults'
health care experiences in seven countries, 2007.
December 23, 2012
Schoen C, Osborn R, Doty M, et al. Toward higher-performance health systems: adults' health care
experiences in seven countries, 2007. Health Aff (Millwood). 2007;26(6):w717-734.
https://psnet.ahrq…
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psnet.ahrq.gov/node/49640/psn-pdf
November 01, 2011 - Bernheim Project Coordinator
Institute for Healthcare Optimization
References
1. Sentinel Event.
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psnet.ahrq.gov/node/49538/psn-pdf
June 01, 2007 - Several weeks later, she received a phone
call from the study coordinator reporting that a "major abnormality
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psnet.ahrq.gov/node/49710/psn-pdf
May 01, 2014 - transfer should take place
either through the electronic medical record or via a pharmacist or discharge coordinator
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psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
May 16, 2022 - When the Meds Don’t Reach the Bed
Citation Text:
Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/communication-failure-whos-charge
April 01, 2018 - Communication Failure—Who's in Charge?
Citation Text:
Fackler J, Schwartz JM. Communication Failure—Who's in Charge?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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