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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72850/psn-pdf
    March 17, 2021 - Nurse sensemaking for responding to patient and family safety concerns. March 17, 2021 Groves PS, Bunch JL, Cannava KE, et al. Nurse sensemaking for responding to patient and family safety concerns. Nurs Res. 2021;70(2):106-113. doi:10.1097/nnr.0000000000000487. https://psnet.ahrq.gov/issue/nurse-sensemaking-respo…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837517/psn-pdf
    June 22, 2022 - Zero: Eliminating Unnecessary Deaths in a Post- pandemic NHS. June 22, 2022 Hunt J. London, UK: Swift Press; 2022. ISBN: ? 9781800751224. https://psnet.ahrq.gov/issue/zero-eliminating-unnecessary-deaths-post-pandemic-nhs The National Health Service (NHS) has been a leader in patient safety for over 20 years, and y…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73592/psn-pdf
    August 11, 2021 - Using performance improvement to enhance time-out compliance and prevent wrong-site surgery. August 11, 2021 Vance ME, Proctor T, Schmidt KA. Using performance improvement to enhance time-out compliance and prevent wrong-site surgery. AORN J. 2021;113(6):635-642. doi:10.1002/aorn.13413. https://psnet.ahrq.gov/issu…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34730/psn-pdf
    October 29, 2013 - Medication Errors. 2nd ed. October 29, 2013 Cohen MR, ed. Washington DC: American Pharmacists Association; 2007. https://psnet.ahrq.gov/issue/medication-errors-2nd-ed Cohen, executive director of the Institute for Safe Medication Practices (ISMP), combined 25 years of experience as a leader in medication safety wi…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44667/psn-pdf
    March 15, 2016 - Incorporating metacognition into morbidity and mortality rounds: the next frontier in quality improvement. March 15, 2016 Katz D, Detsky AS. Incorporating metacognition into morbidity and mortality rounds: The next frontier in quality improvement. J Hosp Med. 2016;11(2):120-2. doi:10.1002/jhm.2505. https://psnet.a…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40817/psn-pdf
    November 01, 2011 - Electronic prescribing within an electronic health record reduces ambulatory prescribing errors. November 1, 2011 Dupree E, Anderson R, McEvoy MD, et al. Professionalism: a necessary ingredient in a culture of safety. Jt Comm J Qual Patient Saf. 2011;37(10):447-455. https://psnet.ahrq.gov/issue/electronic-prescrib…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42618/psn-pdf
    January 04, 2015 - Principles supporting dynamic clinical care teams: an American College of Physicians position paper. January 4, 2015 Doherty RB, Crowley RA, Physicians H and PPC of the AC of. Principles supporting dynamic clinical care teams: an American College of Physicians position paper. Ann Intern Med. 2013;159(9):620-6. doi…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852805/psn-pdf
    August 23, 2023 - Unstoppable: this doctor has been investigated at every level of government. How is he still practicing? August 23, 2023 Waldman A. ProPublica. August 9, 2023 https://psnet.ahrq.gov/issue/unstoppable-doctor-has-been-investigated-every-level-government-how-he- still-practicing Systemic failures can enable poo…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72696/psn-pdf
    February 03, 2021 - Exploring the association between organizational safety climate, failure to rescue, and mortality in inpatient surgical units. February 3, 2021 Bacon CT, McCoy TP, Henshaw DS. Exploring the Association Between Organizational Safety Climate, Failure to Rescue, and Mortality in Inpatient Surgical Units. J Nurs Adm. …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74042/psn-pdf
    November 03, 2021 - An Investigation into the Death of Baby J at University Hospitals Bristol and Weston NHS Foundation Trust. November 3, 2021 Manchester, UK: Parliamentary and Health Service Ombudsman; October 2021. https://psnet.ahrq.gov/issue/investigation-death-baby-j-university-hospitals-bristol-and-weston-nhs- foundation-trust…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45312/psn-pdf
    July 27, 2016 - Perioperative safety: learning, not taking, from aviation. July 27, 2016 Neuhaus C, Hofer S, Hofmann G, et al. Perioperative Safety: Learning, Not Taking, from Aviation. Anesth Analg. 2016;122(6):2059-63. doi:10.1213/ANE.0000000000001315. https://psnet.ahrq.gov/issue/perioperative-safety-learning-not-taking-aviatio…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42663/psn-pdf
    October 16, 2023 - Patient Safety: A Case-based Innovative Playbook for Safer Care. Second Edition. October 16, 2023 Agrawal A, Bhatt J, eds. Cham, Switzerland, Springer Nature; 2023. ISBN: 9783031359330. https://psnet.ahrq.gov/issue/patient-safety-case-based-innovative-playbook-safer-care-second-edition This publication describes a…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41228/psn-pdf
    August 02, 2012 - Identifying the latent failures underpinning medication administration errors: an exploratory study. August 2, 2012 Lawton R, Carruthers S, Gardner P, et al. Identifying the latent failures underpinning medication administration errors: an exploratory study. Health Serv Res. 2012;47(4):1437-1459. doi:10.1111/j.1475…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39960/psn-pdf
    September 19, 2016 - Respectful Management of Serious Clinical Adverse Events. Second Edition. September 19, 2016 Conway J, Federico F, Stewart K, Campbell MJ. Cambridge, MA: Institute for Healthcare Improvement; 2011. https://psnet.ahrq.gov/issue/respectful-management-serious-clinical-adverse-events-second-edition This white paper e…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837904/psn-pdf
    August 24, 2022 - A state-of-the-art review of speaking up in healthcare. August 24, 2022 Violato E. A state-of-the-art review of speaking up in healthcare. Adv Health Sci Educ Theory Pract. 2022;27(4):1177-1194. doi:10.1007/s10459-022-10124-8. https://psnet.ahrq.gov/issue/state-art-review-speaking-healthcare Speaking up behaviors …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866443/psn-pdf
    August 07, 2024 - Cultivate discussions in a psychologically safe workplace: part 1 and part II. August 7, 2024 ISMP Medication Safety Alert! Acute Care. July 11, 2024;29;(14):1-3; July 25, 2024;29(15):1-5. https://psnet.ahrq.gov/issue/cultivate-discussions-psychologically-safe-workplace-part-1-and-part-ii Psychological safety is c…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73093/psn-pdf
    March 31, 2021 - Leadership through crisis: fighting the fatigue pandemic in healthcare during COVID-19. March 31, 2021 Whelehan DF, Algeo N, Brown DA. Leadership through crisis: fighting the fatigue pandemic in healthcare during COVID-19. BMJ Leader. 2021;5:108-112. doi:10.1136/leader-2020-000419. https://psnet.ahrq.gov/issue/lea…

  18. Webcast - Sept. 9: Patient Safety in Medical Offices: Using SOPS Tools to Drive Improvement | Agency for Healthcare Research and Quality

    www.ahrq.gov/news/sops-webcast.html
    August 01, 2025 - Webcast - Sept. 9: Patient Safety in Medical Offices: Using SOPS Tools to Drive Improvement Date:   Tuesday, September 9 Time:   1:00 - 2:30 p.m. ET Register now for the upcoming webinar “Patient Safety in Medical Offices: Using SOPS Tools to Drive Improvement”. This webinar will highlight how the University o…

  19. Assemble the Team | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cusp/modules/assemble/index.html
    July 01, 2018 - Assemble the Team The Assemble the Team module of the CUSP Toolkit addresses CUSP team composition for your quality improvement initiative. This module presents five concepts that address— The importance of teamwork and team composition to the CUSP initiative. How to develop a strategy to build an eff…

  20. Factors that Impact Perinatal Care Experience and Outcomes | Agency for Healthcare Research and Quality

    www.ahrq.gov/ncepcr/about/pcr-webinar-series/perinatal-care-experience.html
    April 01, 2025 - Factors that Impact Perinatal Care Experience and Outcomes This AHRQ National Center for Excellence in Primary Care Research (NCEPCR) webinar about the role of primary care in perinatal care and outcomes highlighted research on delivering respectful maternity care, insurance disruptions on maternal healthcare, …
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