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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39563/psn-pdf
    June 02, 2010 - Implementing a fatigue countermeasures program for nurses: a focus group analysis. June 2, 2010 Scott LD, Hofmeister N, Rogness N, et al. Implementing a fatigue countermeasures program for nurses: a focus group analysis. J Nurs Adm. 2010;40(5):233-40. doi:10.1097/NNA.0b013e3181da4078. https://psnet.ahrq.gov/issue/…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50604/psn-pdf
    October 30, 2019 - Speaking up about patient safety requires an observant questioner and a high index of suspicion. October 30, 2019 ISMP Medication Safety Alert! Acute Care Edition. October 10, 2019;24. https://psnet.ahrq.gov/issue/speaking-about-patient-safety-requires-observant-questioner-and-high-index- suspicion The bundling o…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45265/psn-pdf
    July 13, 2016 - Tackling disrespectful, unprofessional provider behaviors. July 13, 2016 Tackling Disrespectful, Unprofessional Provider Behaviors. ED Manage. 2016;28(6):S1-S4. https://psnet.ahrq.gov/issue/tackling-disrespectful-unprofessional-provider-behaviors Disrespectful conduct among health care providers can hinder safe ca…
  4. www.ahrq.gov/teamstepps-program/curriculum/implement/pre-ready.html
    January 01, 2024 - Teaching Pre-Implementation Readiness Present Slide 10, "Assessing Your Readiness"; note the importance of objectively assessing whether an organization is ready to implement TeamSTEPPS. Have people share times when their organizations attempted a change they weren’t really prepared for. Using Slide 11, “…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60703/psn-pdf
    January 01, 2021 - Human factors and ergonomics at time of crises: the Italian experience coping with COVID19. July 22, 2020 Albolino S, Dagliana G, Tanzini M, et al. Human factors and ergonomics at time of crises: the Italian experience coping with COVID-19. Int J Qual Health Care. 2021;33(1):mzaa04. doi:10.1093/intqhc/mzaa049. ht…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867699/psn-pdf
    June 01, 2023 - Toolkit for Improving Surgical Care and Recovery. June 1, 2023 Agency for Healthcare Research and Quality. Toolkit for Improving Surgical Care and Recovery. June 2023. https://psnet.ahrq.gov/issue/toolkit-improving-surgical-care-and-recovery Improving patient experience fosters better communication, trust, and col…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38582/psn-pdf
    May 22, 2023 - Serious Reportable Events in Massachusetts. May 22, 2023 Fillo KT, Saunders K. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; 2023. https://psnet.ahrq.gov/issue/serious-reportable-events-massachusetts This reoccurring report compiles patient safety…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45990/psn-pdf
    August 24, 2022 - Medication Safety Certificate Program. August 24, 2022 American Society of Health-System Pharmacists, Institute for Safe Medication Practices. https://psnet.ahrq.gov/issue/medication-safety-certificate-program Leadership commitment to reduce medication errors can help address this safety problem. This certificate …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45462/psn-pdf
    August 31, 2016 - Learning From Mistakes. August 31, 2016 London, UK: Parliamentary and Health Service Ombudsman; July 18, 2016. ISBN: 9781474135764. https://psnet.ahrq.gov/issue/learning-mistakes The National Health Service (NHS) has a history of sharing analyses of problems in its system. Summarizing an NHS investigation into the…
  10. www.ahrq.gov/antibiotic-use/long-term-care/improve/intervention.html
    June 01, 2021 - Choosing an Intervention and Measuring Change A decision on an intervention should be informed by input from frontline staff and the antibiotic stewardship team. The Staff Safety Assessment Form and the Learning from Antibiotic-Associated Adverse Events Form will help your team obtain that information. Th…
  11. Four Moments Poster (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/four-moments/poster-one-option.pdf
    November 01, 2019 - Four Moments Poster AHRQ Pub. No. 17(20)-0028-EF November 2019 Moment 1 occurs at the time initiation of antibiotic therapy is considered: Ask, “Does my patient have an infection that requires antibiotics?” occurs when the dec…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36799/psn-pdf
    November 28, 2016 - The evolving role of health educators in advancing patient safety: forging partnerships and leading change. November 28, 2016 Mercurio A. The evolving role of health educators in advancing patient safety: forging partnerships and leading change. Health Promot Pract. 2007;8(2):119-27. https://psnet.ahrq.gov/issue/e…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73860/psn-pdf
    September 22, 2021 - A system safety approach to assessing risks in the sepsis treatment process. September 22, 2021 Kaya GK. A system safety approach to assessing risks in the sepsis treatment process. Appl Ergon. 2021;94:103408. doi:10.1016/j.apergo.2021.103408. https://psnet.ahrq.gov/issue/system-safety-approach-assessing-risks-sep…
  14. pso.ahrq.gov/faq/what-is-a-pso
    SHARE: What is a PSO? A Patient Safety Organization (PSO) works with healthcare providers to help them improve patient safety and healthcare quality and encourage a culture of safety. PSOs analyze data voluntarily reported by providers and provide feedback aimed…
  15. digital.ahrq.gov/ahrq-funded-projects/development-clinical-decision-support-tool-facilitating-naturalistic-decision/citation/survey
    January 01, 2023 - Survey-based work system assessment to facilitate large-scale dissemination of healthcare quality improvement programs. Citation Xie A, Koontz DW, Voskertchian A, Fackler JC, Milstone AM, Woods-Hill CZ. Survey-based work system assessment to facilitate large-scale dissemination of healthcare quality …
  16. digital.ahrq.gov/sites/default/files/docs/publication/r18hs017234-wagner-final-report-2011.pdf
    January 01, 2011 - Changes in PFCC cultural attitudes over time Table 5.
  17. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/actionplan-trip-slides.pptx
    January 01, 2017 - Create a plan to move from current to target condition Assess then address cultural barriers Include
  18. www.ahrq.gov/news/events/nac/2019-04-nac/nacmtg0419-minutes.html
    July 01, 2019 - Cultural aspects drive decision making.
  19. psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-building-capacity-patient-safety
    July 31, 2023 - In Conversation with... Regina Hoffman about Building Capacity for Patient Safety Regina M. Hoffman, MBA, RN, Cindy Manaoat Van, MHSA, CPPS,Sarah E. Mossburg, RN, PhD | July 31, 2023  Also Read the Essay Citation Text: In Conversation with.. Regina Hoffman about…
  20. psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
    May 01, 2007 - Patient Safety in the United Kingdom: Evolution and Progress Susan Burnett and Charles Vincent, PhD | May 1, 2007  Also Read a Conversation View more articles from the same authors. Citation Text: Burnett S, Vincent CA. Patient Safety in the United Kingdom: Evol…