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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39381/psn-pdf
    March 17, 2010 - Getting it right when things go wrong. March 17, 2010 Pettker CM, Funai EF. Getting it right when things go wrong. JAMA. 2010;303(10):977-8. doi:10.1001/jama.2010.256. https://psnet.ahrq.gov/issue/getting-it-right-when-things-go-wrong This brief commentary discusses the relationship between blame, accountability, …

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38262/psn-pdf
    September 29, 2017 - Roadmap for patient safety research: approaches and roadforks. September 29, 2017 Hofoss D, Deilkås E. Roadmap for patient safety research: approaches and roadforks. Scand J Public Health. 2008;36(8):812-7. doi:10.1177/1403494808096168. https://psnet.ahrq.gov/issue/roadmap-patient-safety-research-approaches-and-ro…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42241/psn-pdf
    May 01, 2013 - Special Issue on Teamwork. May 1, 2013 Salas E, Rosen MA, eds. BMJ Qual Saf. 2013;22(5):369-448.   https://psnet.ahrq.gov/issue/special-issue-teamwork Articles in this special issue explore theory-driven and simulation-based approaches to improve teamwork in health care. https://psnet.ahrq.gov/issue/special-…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39909/psn-pdf
    October 06, 2010 - Safety Climate: New Developments in Conceptualization, Theory, and Research. October 6, 2010 Huang YH, Chen PY, Grosch JW, eds. Accid Anal Prev. 2010;42:1421-1522.    https://psnet.ahrq.gov/issue/safety-climate-new-developments-conceptualization-theory-and-research Articles in this special issue highligh…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36467/psn-pdf
    October 02, 2017 - Promoting collaboration and transparency in patient safety. October 2, 2017 Apold J, Daniels T, Sonneborn M. Promoting collaboration and transparency in patient safety. Jt Comm J Qual Patient Saf. 2006;32(12):672-675. https://psnet.ahrq.gov/issue/promoting-collaboration-and-transparency-patient-safety This articl…

  6. Four Moments of Antibiotic Decision Making Poster (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/poster-4x6-four-moments-single.pdf
    June 01, 2021 - Four Moments of Antibiotic Decision Making Poster AHRQ Pub. No. 17(21)-0029 June 2021 Does the resident have symptoms that suggest an infection? What type of infection is it? Have we collected appropriate cultures before starting antibiotics? What empiric therapy should be initiated? What duration …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37045/psn-pdf
    September 30, 2011 - Understanding and attitudes towards patient safety concepts in obstetrics. September 30, 2011 Nabhan A, Ahmed-Tawfik MS. Understanding and attitudes towards patient safety concepts in obstetrics. Int J Gynaecol Obstet. 2007;98(3):212-6. https://psnet.ahrq.gov/issue/understanding-and-attitudes-towards-patient-safet…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41823/psn-pdf
    November 07, 2012 - Patient safety: some progress and many challenges. November 7, 2012 Gluck PA. Patient safety: some progress and many challenges. Obstet Gynecol. 2012;120(5):1149-1159. https://psnet.ahrq.gov/issue/patient-safety-some-progress-and-many-challenges This commentary summarizes efforts to improve patient safety since To …

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43300/psn-pdf
    June 25, 2014 - VA punished critics on staff, doctors assert. June 25, 2014 Lichtblau E. https://psnet.ahrq.gov/issue/va-punished-critics-staff-doctors-assert This newspaper article reports how a "culture of silence" at Veterans Affairs hospitals discouraged staff from speaking up about safety and quality concerns related to the …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34038/psn-pdf
    December 22, 2008 - Whither Challenger, wither Columbia: management decision making and the knowledge analytic. December 22, 2008 Garrett TM. https://psnet.ahrq.gov/issue/whither-challenger-wither-columbia-management-decision-making-and- knowledge-analytic The decision making of management for the Challenger and Columbia shuttle mis…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39243/psn-pdf
    February 10, 2015 - Advancing nursing home quality through quality improvement itself. February 10, 2015 Werner RM, Konetzka RT. Advancing Nursing Home Quality Through Quality Improvement Itself. Health Aff. 2010;29(1):81-86. doi:10.1377/hlthaff.2009.0555. https://psnet.ahrq.gov/issue/advancing-nursing-home-quality-through-quality-im…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42189/psn-pdf
    April 17, 2013 - Avoiding medical emergencies. April 17, 2013 Omar Y. Avoiding medical emergencies. Br Dent J. 2013;214(5):255-9. doi:10.1038/sj.bdj.2013.217. https://psnet.ahrq.gov/issue/avoiding-medical-emergencies This commentary details how to assess and address risks in dental care and highlights checklists as a tool to help …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36034/psn-pdf
    September 27, 2010 - One intensive care nursery's experience with enhancing patient safety. September 27, 2010 Alton M, Mericle J, Brandon D. One intensive care nursery's experience with enhancing patient safety. Adv Neonatal Care. 2006;6(3):112-9. https://psnet.ahrq.gov/issue/one-intensive-care-nurserys-experience-enhancing-patient-s…

  14. Improving Patient Safety by Engaging Patients and Families (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/ps-research-summary-pfe.pdf
    April 30, 2025 - Attendees included professionals in education and treatment of diabetes, cultural competency, the arts … (Products) Jennifer Carroll University of Rochester Rochester, New York R03 HS14105 [Grant] Cultural … Maternal Health in African Women 2003-2005 $99,998 Final Report Purpose: To identify specific cultural … through interventions focused on increasing patient engagement and physician communication skills across cultural

  15. AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Enhancing Teamwork and Leadership (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-teamwork-leadership.pdf
    April 30, 2025 - AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Enhancing Teamwork and Leadership AHRQ-Funded Patient Safety Project Highlights Improving Healthcare Safety by Enhancing Teamwork and Leadership Overview According to the Joint Commission, in 2022, failures in communication, teamwork, a…

  16. Final Progress Report: Physician Perspectives Regarding the Use of Shared Decision Making in the Emergency Department (pdf file)

    www.ahrq.gov/sites/default/files/2024-05/schoenfeld-report.pdf
    January 01, 2024 - One theme was noted as facilitating resident training: the changing culture (cultural shifts toward

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42061/psn-pdf
    October 05, 2015 - Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. October 5, 2015 Ganz DA, Huang C, Saliba D, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2013. AHRQ Publication No. 13-0015-EF. https://psnet.ahrq.gov/issue/preventing-falls-hospitals-toolkit-improving-quality-care…

  18. Hospitals | Agency for Healthcare Research and Quality

    www.ahrq.gov/topics/hospitals.html
    Topic: Hospitals AHRQ has research, tools, and resources for hospitals and health systems to improve the safety and quality of care. CAHPS Child Hospital Survey (Child HCAHPS) Toolkit Decolonization Hospital Survey on Patient Safety Culture Improving Pat…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40111/psn-pdf
    December 14, 2012 - Disruptive behavior affects hospital financial health. December 14, 2012 Rosenstein AH. Measuring and managing the economic impact of disruptive behaviors in the hospital. Journal of healthcare risk management : the journal of the American Society for Healthcare Risk Management. 2010;30(2):20-6. doi:10.1002/jhrm.20…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50767/psn-pdf
    August 12, 2024 - 2024 IHI Forum August 12, 2024 Institute for Healthcare Improvement. Orlando World Center Marriott, Orlando, FL, December 9-11, 2024. https://psnet.ahrq.gov/issue/2024-ihi-forum This hybrid conference will offer workshops and interactive sessions exploring strategies from within health care and beyond to improve h…
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