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psnet.ahrq.gov/issue/aorn-guidance-statement-creating-patient-safety-culture
March 14, 2018 - Organizational Policy/Guidelines
AORN guidance statement: creating a patient safety culture.
Citation Text:
Nurses A of periOR. AORN guidance statement: creating a patient safety culture. AORN journal. 2006;83(4):936-42.
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psnet.ahrq.gov/issue/ismp-medication-safety-self-assessment-high-alert-medications
June 07, 2017 - Measurement Tool/Indicator
ISMP Medication Safety Self Assessment for High-Alert Medications.
Citation Text:
ISMP Medication Safety Self Assessment for High-Alert Medications. Horsham, PA: Institute for Safe Medication Practices; 2017.
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psnet.ahrq.gov/issue/measuring-success-regional-medication-safety-program-hospitals
June 27, 2018 - Book/Report
Measuring the Success of the Regional Medication Safety Program for Hospitals.
Citation Text:
Measuring the Success of the Regional Medication Safety Program for Hospitals. Pelczarski K, Fricker M, Morris J. Philadelphia, PA: Health Care Improvement Foundation; 2005.
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psnet.ahrq.gov/issue/safety-management-systems-introduction-healthcare
February 14, 2024 - Book/Report
Safety Management Systems - an Introduction for Healthcare.
Citation Text:
Safety Management Systems - an Introduction for Healthcare. Dorset, UK: Health Services Safety Investigations Body; October 2023.
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psnet.ahrq.gov/issue/anesthesia-patient-safety-foundation
January 02, 2011 - Multi-use Website
Anesthesia Patient Safety Foundation.
Citation Text:
Anesthesia Patient Safety Foundation. P.O. Box 6668, Rochester, MN 55903.
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psnet.ahrq.gov/issue/pact-collaborative-pathway-accountability-compassion-and-transparency
February 05, 2014 - Multi-use Website
PACT Collaborative: Pathway to Accountability, Compassion and Transparency.
Citation Text:
PACT Collaborative: Pathway to Accountability, Compassion and Transparency. Ariadne Labs, Brigham and Women’s Hospital, Harvard TH Chan School of Public Health.
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psnet.ahrq.gov/issue/arv-medication-errors-experience-community-based-hiv-specialty-clinic-and-review-literature
March 29, 2010 - Study
ARV medication errors: experience of a community-based HIV specialty clinic and review of the literature.
Citation Text:
ARV medication errors: experience of a community-based HIV specialty clinic and review of the literature. Cocohoba J; Dong BJ.
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psnet.ahrq.gov/issue/blaming-others-threatening-events
November 25, 2009 - Review
Classic
Blaming others for threatening events.
Citation Text:
Blaming others for threatening events. Tennen H; Affleck G.
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psnet.ahrq.gov/issue/dana-farber-cancer-institute-principles-fair-and-just-culture
January 11, 2023 - Organizational Policy/Guidelines
Dana-Farber Cancer Institute Principles of a Fair and Just Culture.
Citation Text:
Dana-Farber Cancer Institute Principles of a Fair and Just Culture. Dana-Farber Cancer Institute.
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psnet.ahrq.gov/patient-safety-101
March 26, 2025 - Patient Safety 101: The Fundamentals
What is Patient Safety?
The breadth of the field of patient safety is captured in various definitions. It has been defined as avoiding harm to patients from care that is intended to help them. 1 It involves the prevention and mitigation of harm caused by err…
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psnet.ahrq.gov/issue/no-one-coming-hospice-patients-abandoned-deaths-door
June 29, 2016 - Newspaper/Magazine Article
'No one is coming': hospice patients abandoned at death's door.
Citation Text:
'No one is coming': hospice patients abandoned at death's door. Aleccia J; Bailey M.
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psnet.ahrq.gov/issue/medical-error-reporting-system-could-boost-patient-safety
December 14, 2022 - Newspaper/Magazine Article
Medical Error Reporting System Could Boost Patient Safety.
Citation Text:
Medical Error Reporting System Could Boost Patient Safety. Ebright PR; Rapala K. Indianapolis, IN: Center for Urban Policy and the Environment, School of Public and Environmental Affa…
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psnet.ahrq.gov/issue/global-state-patient-safety-2023
April 06, 2016 - Book/Report
Global State of Patient Safety 2023.
Citation Text:
Global State of Patient Safety 2023. Illingworth J, Shaw A, Fernandez et al. London UK: Imperial College London; 2023.
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psnet.ahrq.gov/issue/adverse-health-care-events-reporting-system-what-have-we-learned
February 28, 2015 - Book/Report
Adverse Health Care Events Reporting System: What Have We Learned?
Citation Text:
Adverse Health Care Events Reporting System: What Have We Learned? St. Paul, MN: Minnesota Department of Health; January 2009.
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psnet.ahrq.gov/issue/improving-reliability-health-care
November 18, 2011 - Book/Report
Improving the Reliability of Health Care.
Citation Text:
Improving the Reliability of Health Care. Nolan T, Resar R, Haraden C, et al. Boston, MA: Institute for Healthcare Improvement; 2004.
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psnet.ahrq.gov/node/49767/psn-pdf
August 21, 2016 - Falling Between the Cracks in the Software
August 21, 2016
Adler-Milstein J. Falling Between the Cracks in the Software. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/falling-between-cracks-software
The Case
A 61-year-old man with a history of osteoarthritis was scheduled for a total knee replacement. Prio…
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psnet.ahrq.gov/node/49692/psn-pdf
September 01, 2013 - A Picture Speaks 1000 Words
September 1, 2013
Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/picture-speaks-1000-words
The Case
A 62-year-old man with a past medical history of hypertension, hyperlipidemia, and type A aortic dissection
repair presented with chest p…
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psnet.ahrq.gov/primer/triggers-and-trigger-tools
September 15, 2024 - Triggers and Trigger Tools
Citation Text:
Triggers and Trigger Tools. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/49392/psn-pdf
April 01, 2003 - Long-Term Care Standards Manual (1996), Standards RI.2.6 (defining restraint), TX.8
(emphasizing a restraint-free
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psnet.ahrq.gov/node/837748/psn-pdf
August 05, 2022 - addition to hiring and training staff dedicated to performing BPMH, the MARQUIS study showed that
defining