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psnet.ahrq.gov/node/45349/psn-pdf
July 27, 2016 - An insurer's care transition program emphasizes
medication reconciliation, reduces readmissions and
costs.
July 27, 2016
Polinski JM, Moore JM, Kyrychenko P, et al. An Insurer's Care Transition Program Emphasizes Medication
Reconciliation, Reduces Readmissions And Costs. Health Aff (Millwood). 2016;35(7):1222-9.
…
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psnet.ahrq.gov/node/41774/psn-pdf
October 24, 2012 - Health information technology and its effects on hospital
costs, outcomes, and patient safety.
October 24, 2012
Encinosa W, Bae J. Health information technology and its effects on hospital costs, outcomes, and patient
safety. Inquiry. 2011;48(4):288-303.
https://psnet.ahrq.gov/issue/health-information-technology-a…
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psnet.ahrq.gov/node/44517/psn-pdf
October 21, 2015 - Electronic health record challenges, workarounds, and
solutions observed in practices integrating behavioral
health and primary care.
October 21, 2015
Cifuentes M, Davis M, Fernald D, et al. Electronic Health Record Challenges, Workarounds, and Solutions
Observed in Practices Integrating Behavioral Health and Prim…
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psnet.ahrq.gov/node/41996/psn-pdf
July 03, 2014 - Effects of duty hour restrictions on core competencies,
education, quality of life, and burnout among general
surgery interns.
July 3, 2014
Antiel RM, Reed DA, Van Arendonk K, et al. Effects of duty hour restrictions on core competencies,
education, quality of life, and burnout among general surgery interns. JAMA …
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psnet.ahrq.gov/node/72741/psn-pdf
February 17, 2021 - The I-READI quality and safety framework: a health
system’s response to airway complications in
mechanically ventilated patients with Covid-19.
February 17, 2021
Ginestra JC, Atkins JH, Mikkelsen ME, et al. The I-READI Quality and Safety Framework: a health
system’s response to airway complications in mechanically…
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psnet.ahrq.gov/node/72566/psn-pdf
January 01, 2021 - Incidence, nature and causes of avoidable significant
harm in primary care in England: retrospective case note
review.
December 16, 2020
Avery AJ, Sheehan C, Bell BG, et al. Incidence, nature and causes of avoidable significant harm in primary
care in England: retrospective case note review. BMJ Qual Saf. 2021;30(…
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psnet.ahrq.gov/node/47529/psn-pdf
January 21, 2019 - Community-acquired and hospital-acquired medication
harm among older inpatients and impact of a state-wide
medication management intervention.
January 21, 2019
Pellegrin K, Lozano A, Miyamura J, et al. Community-acquired and hospital-acquired medication harm
among older inpatients and impact of a state-wide medica…
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psnet.ahrq.gov/node/38579/psn-pdf
February 18, 2011 - Transitions of Care Consensus Policy Statement
American College of Physicians-Society of General
Internal Medicine-Society of Hospital Medicine-American
Geriatrics Society-American College of Emergency
Physicians-Society of Academic Emergency Medicine.
February 18, 2011
Snow V, Beck D, Budnitz T, et al. Transitio…
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psnet.ahrq.gov/node/45963/psn-pdf
March 22, 2017 - Call to Action: Preventable Health Care Harm Is a Public
Health Crisis and Patient Safety Requires a Coordinated
Public Health Response.
March 22, 2017
Boston, MA: National Patient Safety Foundation; March 2017.
https://psnet.ahrq.gov/issue/call-action-preventable-health-care-harm-public-health-crisis-and-patient-…
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psnet.ahrq.gov/node/43681/psn-pdf
June 03, 2016 - Learning from failure: the need for independent safety
investigation in healthcare.
June 3, 2016
Macrae C, Vincent CA. Learning from failure: the need for independent safety investigation in healthcare. J
R Soc Med. 2014;107(11):439-443. doi:10.1177/0141076814555939.
https://psnet.ahrq.gov/issue/learning-failure-n…
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psnet.ahrq.gov/node/46830/psn-pdf
May 30, 2018 - A call to bridge across silos during care transitions.
May 30, 2018
Sheikh F, Gathecha E, Bellantoni M, et al. A Call to Bridge Across Silos during Care Transitions. Jt Comm
J Qual Patient Saf. 2018;44(5):270-278. doi:10.1016/j.jcjq.2017.10.006.
https://psnet.ahrq.gov/issue/call-bridge-across-silos-during-care-tran…
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psnet.ahrq.gov/node/34083/psn-pdf
June 30, 2011 - Handoff strategies in settings with high consequences for
failure: lessons for health care operations.
June 30, 2011
Patterson ES. Handoff strategies in settings with high consequences for failure: lessons for health care
operations. Int J Qual Health Care. 2004;16(2):125-132. doi:10.1093/intqhc/mzh026.
https://ps…
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psnet.ahrq.gov/node/39645/psn-pdf
August 03, 2010 - Monitoring and reducing central line-associated
bloodstream infections: a national survey of state
hospital associations.
August 3, 2010
Murphy DJ, Needham DM, Goeschel CA, et al. Monitoring and reducing central line-associated
bloodstream infections: a national survey of state hospital associations. Am J Med Qual…
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psnet.ahrq.gov/node/44202/psn-pdf
June 10, 2015 - Medication reconciliation to facilitate transitions of care
after hospitalization.
June 10, 2015
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.
https://psnet.ahrq.gov/issue/medication-reconci…
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psnet.ahrq.gov/innovations-exchange
May 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,…
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psnet.ahrq.gov/node/49863/psn-pdf
May 01, 2019 - Good Catch in the Operating Room
May 1, 2019
Day J, Paige JT. Good Catch in the Operating Room. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/good-catch-operating-room
The Case
A 46-year-old woman with extensive history of back pain from lumbar stenosis was scheduled for an
elective laminectomy and spinal…
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psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
February 01, 2017 - In Conversation With… Amy C. Edmondson, PhD, AM
February 1, 2017
Also Read an Essay
Citation Text:
In Conversation With… Amy C. Edmondson, PhD, AM. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…
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psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
February 01, 2017 - New Insights About Team Training From a Decade of TeamSTEPPS
David P. Baker, PhD; James B. Battles, PhD; Heidi B. King, MS | February 1, 2017
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Baker DP, King HB, Battles J. New Ins…
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psnet.ahrq.gov/node/38569/psn-pdf
May 20, 2009 - Reducing health care hazards: lessons from the
Commercial Aviation Safety Team.
May 20, 2009
Pronovost P, Goeschel CA, Olsen KL, et al. Reducing health care hazards: lessons from the commercial
aviation safety team. Health Aff (Millwood). 2009;28(3):w479-89. doi:10.1377/hlthaff.28.3.w479.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/36324/psn-pdf
December 10, 2008 - 2006 Update on Consumers' Views of Patient Safety and
Quality Information.
December 10, 2008
Washington DC: Kaiser Family Foundation; 2006.
https://psnet.ahrq.gov/issue/2006-update-consumers-views-patient-safety-and-quality-information
This survey follows up on a prior study from 2004, asking patients about their…