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  1. Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and regulation in three healthcare settings. | PSNet

    psnet.ahrq.gov/issue/publication-inspection-frameworks-qualitative-study-exploring-impact-quality-improvement-and
    August 10, 2022 - Study Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and regulation in three healthcare settings. Citation Text: Weenink J-W, Wallenburg I, Leistikow I, et al. Publication of inspection frameworks: a qualitative study exploring the i…

  2. Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network. | PSNet

    psnet.ahrq.gov/issue/design-and-implementation-application-and-associated-services-support-interdisciplinary
    February 15, 2011 - Study Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network. Citation Text: Poon EG, Blumenfeld B, Hamann C, et al. Design and Implementation of an Application and …

  3. System issues leading to "found-on-floor" incidents: a multi-incident analysis. | PSNet

    psnet.ahrq.gov/issue/system-issues-leading-found-floor-incidents-multi-incident-analysis
    August 04, 2021 - Study System issues leading to "found-on-floor" incidents: a multi-incident analysis. Citation Text: Shaw J, Bastawrous M, Burns S, et al. System Issues Leading to “Found-on-Floor” Incidents: A Multi-Incident Analysis. J Patient Saf. 2021;17(1):30-35. doi:10.1097/pts.0000000000000294. …

  4. Incident learning in pursuit of high reliability: implementing a comprehensive, low-threshold reporting program in a large, multisite radiation oncology department. | PSNet

    psnet.ahrq.gov/issue/incident-learning-pursuit-high-reliability-implementing-comprehensive-low-threshold-reporting
    September 27, 2017 - Study Incident learning in pursuit of high reliability: implementing a comprehensive, low-threshold reporting program in a large, multisite radiation oncology department. Citation Text: Gabriel PE, Volz E, Bergendahl HW, et al. Incident learning in pursuit of high reliability: implementi…

  5. Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds. | PSNet

    psnet.ahrq.gov/issue/changes-safety-and-teamwork-climate-after-adding-structured-observations-patient-safety
    August 20, 2018 - Study Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds. Citation Text: Klimmeck S, Sexton B, Schwendimann R. Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds. Jt Comm J Qual Pa…

  6. Safety and risk management interventions in hospitals: a systematic review of the literature. | PSNet

    psnet.ahrq.gov/issue/safety-and-risk-management-interventions-hospitals-systematic-review-literature
    April 01, 2010 - Review Safety and risk management interventions in hospitals: a systematic review of the literature. Citation Text: Dückers M, Faber M, Cruijsberg J, et al. Safety and risk management interventions in hospitals: a systematic review of the literature. Med Care Res Rev. 2009;66(6 Suppl):…

  7. 'It's all about patient safety': an ethnographic study of how pharmacy staff construct medicines safety in the context of polypharmacy. | PSNet

    psnet.ahrq.gov/issue/its-all-about-patient-safety-ethnographic-study-how-pharmacy-staff-construct-medicines-safety
    October 06, 2021 - Study 'It's all about patient safety': an ethnographic study of how pharmacy staff construct medicines safety in the context of polypharmacy. Citation Text: Fudge N, Swinglehurst D. ‘It's all about patient safety’: an ethnographic study of how pharmacy staff construct medicines safety in…

  8. Systematic review on the frequency and quality of reporting patient and public involvement in patient safety research. | PSNet

    psnet.ahrq.gov/issue/systematic-review-frequency-and-quality-reporting-patient-and-public-involvement-patient
    February 17, 2021 - Review Systematic review on the frequency and quality of reporting patient and public involvement in patient safety research. Citation Text: Hammoud S, Alsabek L, Rogers L, et al. Systematic review on the frequency and quality of reporting patient and public involvement in patient safety…

  9. Planning and Implementing the Patient Advocacy Reporting System in the Sanford Health System | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/reports/liability/pichert.html
    August 01, 2017 - Advances in Patient Safety and Medical Liability Planning and Implementing the Patient Advocacy Reporting System in the Sanford Health System Previous Page Next Page Table of Contents Advances in Patient Safety and Medical Liability Preface Acknowledgments Prologue Silence A Commentary Ref…

  10. Initiating Dialysis With a Catheter: Catheter Exit Site Care | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/esrd/resource/dialysis-catheter.html
    January 01, 2015 - Initiating Dialysis With a Catheter: Catheter Exit Site Care This video vignette illustrates proper initiation of dialysis for patients with catheters, as well as proper exit site care. It can be shared with staff as a refresher on current practices and guidelines. ESRD Toolkit Modules The f…

  11. TeamSTEPPS | Agency for Healthcare Research and Quality

    www.ahrq.gov/topics/teamstepps.html
    Topic: TeamSTEPPS TeamSTEPPS ® is a teamwork system designed for health care professionals to help them provide higher quality, safer patient care and to create and sustain a culture of safety. HHS Announces New Challenge Competition to Create Innovative Training Videos to…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38367/psn-pdf
    May 24, 2015 - Pathways for Patient Safety. May 24, 2015 Chicago, IL: Health Research and Educational Trust, Institute for Safe Medication Practices, Medical Group Management Association; 2009. https://psnet.ahrq.gov/issue/pathways-patient-safety This trio of modules provides ambulatory medical practices with tools to develop te…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37423/psn-pdf
    December 19, 2007 - Patient Safety. December 19, 2007 Intern J Health Care Qual Assur. 2007;20(7):555-632. https://psnet.ahrq.gov/issue/patient-safety-5 This special issue includes articles by authors from Australia, Israel, France, Iran, and Belgium that explore ideas such as building a culture of safety, replacing medical equipment…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35601/psn-pdf
    June 21, 2010 - Is employee discipline the solution for patient safety? June 21, 2010 Mace KA. Is employee discipline the solution for patient safety? Nurs Manag. 2005;36(12):57-59. https://psnet.ahrq.gov/issue/employee-discipline-solution-patient-safety The author provides suggestions on how to support a blame-free culture and en…

  15. Best Practices in the Diagnosis and Treatment of Bacteremia | Agency for Healthcare Research and Quality

    www.ahrq.gov/antibiotic-use/acute-care/diagnosis/bacteremia.html
    November 01, 2019 - Best Practices in the Diagnosis and Treatment of Bacteremia After viewing or presenting this presentation viewers will be able to— Review recommendations for appropriate blood culture collection  Develop organism-specific management recommendations for Gram-negative and Gram-positive bacteremia Discus…

  16. Learn From Defects in Care of Mechanically Ventilated Patients: Slide Presentation | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-slides.html
    February 01, 2017 - Learn From Defects in Care of Mechanically Ventilated Patients: Slide Presentation AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients Learn From Defects in Care of Mechanically Ventilated Patients Slide 2: Learning Objectives Af…

  17. Performing SSI Investigations: Slide Presentation

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_ssi_investigation.pptx
    December 01, 2017 - Performing SSI Investigations: Slide Presentation Performing an SSI Investigation AHRQ Safety Program for Surgery Onboarding AHRQ Pub No. 16(18)-0004-15-EF December 2017 SAY: In this module, you’ll learn about performing a surgical site infection or SSI investigation. 1 Learning Objectives After this session, you …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49838/psn-pdf
    August 01, 2018 - An Untimely End Despite End-of-Life Care Planning August 1, 2018 Elia G, Barbour S, Anderson WG. An Untimely End Despite End-of-Life Care Planning. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning The Case A 76-year-old man was admitted to the intensive care unit (…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33687/psn-pdf
    August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health Care August 1, 2009 Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care Perspective Frontline health care providers are challen…

  20. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-mar2023.pdf
    July 14, 2023 - Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare March Meeting Summary Workgroup Goal: Established in response to Senate Report 115-150. The Senate Committee on Appropriations requested “AHRQ t…
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