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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849136/psn-pdf
    May 17, 2023 - Using morbidity and mortality conferences to drive quality improvement and reduce errors. May 17, 2023 Lai B, Horn J, Wilkinson J, et al. Fam Pract Manag. 2023;30(2):13-17. https://psnet.ahrq.gov/issue/using-morbidity-and-mortality-conferences-drive-quality-improvement-and- reduce-errors Morbidity and mortality (…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866203/psn-pdf
    June 26, 2024 - How a major public hospital is protecting doctors by silencing the patients who accuse them. June 26, 2024 Kamb L. NBC News. June 14, 2024, https://psnet.ahrq.gov/issue/how-major-public-hospital-protecting-doctors-silencing-patients-who-accuse- them Transparency is a primary element of an organizational safety cu…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45504/psn-pdf
    January 01, 2018 - Hospital nurses' work environment characteristics and patient safety outcomes: a literature review. December 16, 2017 Lee SE, Scott LD. Hospital Nurses' Work Environment Characteristics and Patient Safety Outcomes: A Literature Review. West J Nurs Res. 2018;40(1):121-145. doi:10.1177/0193945916666071. https://psne…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74169/psn-pdf
    December 08, 2021 - Pointing fingers: verbosity of patient safety narratives is associated with attribution of blame. December 8, 2021 Ackerman RS, Patel SY, Costache M, et al. Anesthesiology News. November 21, 2021. https://psnet.ahrq.gov/issue/pointing-fingers-verbosity-patient-safety-narratives-associated-attribution- bl…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46270/psn-pdf
    April 16, 2018 - Impact of a restraint management bundle on restraint use in an intensive care unit. April 16, 2018 Hall DK, Zimbro KS, Maduro RS, et al. Impact of a Restraint Management Bundle on Restraint Use in an Intensive Care Unit. J Nurs Care Qual. 2018;33(2):143-148. doi:10.1097/NCQ.0000000000000273. https://psnet.ahrq.gov…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37077/psn-pdf
    October 03, 2011 - Sensemaking, safety, and cooperative work in the intensive care unit. October 3, 2011 Albolino S, Cook RI, O’Connor M. Sensemaking, safety, and cooperative work in the intensive care unit. Cog Tech Work. 2006;9(3):131-137. doi:10.1007/s10111-006-0057-5. https://psnet.ahrq.gov/issue/sensemaking-safety-and-cooperati…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841475/psn-pdf
    January 01, 2023 - The second victim of unanticipated adverse events. December 14, 2022 Chen S, Skidmore S, Ferrigno BN, et al. The second victim of unanticipated adverse events. J Thorac Cardiovasc Surg. 2023;166(3):890-894. doi:10.1016/j.jtcvs.2022.09.010. https://psnet.ahrq.gov/issue/second-victim-unanticipated-adverse-events “Se…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60973/psn-pdf
    September 30, 2020 - During the pandemic, aspire to identify and prevent medication errors and to avoid blaming attitudes. September 30, 2020 ISMP Medication Safety Alert! Acute care edition. August 27, 2020;25(17). https://psnet.ahrq.gov/issue/during-pandemic-aspire-identify-and-prevent-medication-errors-and-avoid- blaming-attitudes …

  9. Understanding CAHPS Surveys: A Primer for New Users (Webcast) | Agency for Healthcare Research and Quality

    www.ahrq.gov/cahps/news-and-events/events/webinar-011123.html
    January 01, 2023 - Understanding CAHPS Surveys: A Primer for New Users (Webcast) January 11, 2023 Summary Speakers and Presentation Slides Recording Summary This webcast provided an overview of AHRQ's Consumer Assessment of Healthcare Providers and Systems (CAHPS ® ) surveys, and explained how they focus on patients…

  10. What is the NPSD’s Role in Quality and Patient Safety? | Agency for Healthcare Research and Quality

    www.ahrq.gov/npsd/quality-patient-safety/index.html
    August 01, 2020 - What is the NPSD’s Role in Quality and Patient Safety? By enabling providers, PSOs, and, eventually others to contribute nonidentifiable patient safety data to the NPSD, the stage has been set for breakthroughs in our understanding of how best to improve patient safety. The NPSD will facilitate the aggregation …

  11. Understanding CAHPS Surveys: A Primer for New Users (Webcast) | Agency for Healthcare Research and Quality

    www.ahrq.gov/cahps/news-and-events/events/webinar-011922.html
    April 01, 2022 - Understanding CAHPS Surveys: A Primer for New Users (Webcast) January 19, 2022 Summary Speakers and Presentation Slides Recording Summary This AHRQ webcast provided an overview of CAHPS surveys, explained how they focus on patients' priorities, and built on current research in survey development a…

  12. National Action Alliance for Patient and Workforce Safety Commitment (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/naa-commitment-statement.pdf
    June 02, 2025 - National Action Alliance for Patient and Workforce Safety Commitment National Action Alliance for Patient and Workforce Safety Commitment Vision Safe care everywhere, zero preventable harm for all. Mission A total systems approach to safety that is focused on culture, leadership, and governance; pa�ent a…

  13. In Conversation With… Timothy B. McDonald, MD, JD | PSNet

    psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
    February 26, 2025 - In Conversation With… Timothy B. McDonald, MD, JD April 1, 2019  Citation Text: In Conversation With… Timothy B. McDonald, MD, JD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy C…

  14. Pre-analytical pitfalls: Missing and mislabeled specimens | PSNet

    psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
    April 18, 2018 - Pre-analytical pitfalls: Missing and mislabeled specimens Citation Text: Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: …

  15. Patient Safety Organizations: A Summary of 2014 Profiles (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
    January 01, 2014 - Patient Safety Organizations: A Summary of 2014 Profiles Patient Safety Organizations: A Summary of 2014 Profiles The safety of patients in health care settings remains a national priority and an important challenge. The Patient Safety Organization (PSO) program, which was authorized by the Patient Safety and Qu…

  16. AHRQ Safety Program for MRSA Prevention

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/008-antibiotic-stewardship-slides.pptx
    October 01, 2022 - AHRQ Safety Program for MRSA Prevention AHRQ Safety Program for MRSA Prevention Antibiotic Stewardship and MRSA Reduction ICU & Non-ICU AHRQ Pub. No. 25-0007 October 2024 AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU Antibiotic Stewardship 1 Educational Objectives Understand the goals of antibiotic ste…

  17. U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument | PSNet

    psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-college-medicine
    February 26, 2025 - U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL January …

  18. Reducing Unecessary Urinary catheter Use in the Emergency Department: How to Implement the Process (ppt file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-091013.ppt
    January 01, 2010 - Reducing Unecessary Urinary catheter Use in the Emergency Department: How to Implement the Process The Emergency Department & Catheter Insertions * Mohamad Fakih, MD, MPH St. John Hospital and Medical Center Lisa Wolf, PhD, RN, CEN, FAEN Emergency Nurses Association (ENA) Jeremiah Schuur, MD, MHS, FACEP Brig…

  19. Final Progress Report: Safety Advancement in the Emergency Department (pdf file)

    www.ahrq.gov/sites/default/files/2024-01/hall2-report.pdf
    January 01, 2024 - Final Progress Report: Safety Advancement in the Emergency Department FINAL PROGRESS REPORT PROJECT TITLE: SAFETY ADVANCEMENT IN THE EMERGENCY DEPARTMENT* PRINCIPAL INVESTIGATOR: KENDALL K. HALL, MD, MS (AHRQ, formerly of UNIV of MARYLAND) KEY PERSONNEL: YAN XIAO, PhD (BAYLOR, formerly of UNIV of MARYLAND) ANTHO…

  20. Program Evaluation - PowerPoint Presentation

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_8_program-evaluation.pptx
    July 01, 2023 - Program Evaluation - PowerPoint Presentation Program Evaluation Module 8 of 8 SPPC-II Toolkit JHU & AHRQ for AIM AHRQ Pub. No. 23-0046 July 2023 Hospital AIM Team Leads SPPC-II SCRIPT Welcome to Module 8 of the SPPC-II Teamwork Toolkit. In this module we will discuss aspects related to the evaluation of the p…
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