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psnet.ahrq.gov/node/34780/psn-pdf
March 28, 2005 - Disseminating innovations in health care.
March 28, 2005
Berwick DM. Disseminating Innovations in Health Care. JAMA. 2003;289(15):1969-1975.
doi:10.1001/jama.289.15.1969.
https://psnet.ahrq.gov/issue/disseminating-innovations-health-care
This commentary and review discusses the ability to adopt growing numbers of …
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psnet.ahrq.gov/node/47222/psn-pdf
October 03, 2018 - Decision support tools, systems, and artificial intelligence
in cardiac imaging.
October 3, 2018
Massalha S, Clarkin O, Thornhill R, et al. Decision Support Tools, Systems, and Artificial Intelligence in
Cardiac Imaging. Can J Cardiol. 2018;34(7):827-838. doi:10.1016/j.cjca.2018.04.032.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/45520/psn-pdf
October 05, 2016 - Defining excellence: next steps for practicing clinicians
seeking to prevent diagnostic error.
October 5, 2016
Foster PN, Klein JR. Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic
error. J Community Hosp Intern Med Perspect. 2016;6(4):31994. doi:10.3402/jchimp.v6.31994.
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psnet.ahrq.gov/node/866190/psn-pdf
June 26, 2024 - What is diagnostic safety? A review of safety science
paradigms and rethinking paths to improving diagnosis.
June 26, 2024
Choi JJ. What is diagnostic safety? A review of safety science paradigms and rethinking paths to improving
diagnosis. Diagnosis (Berl). 2024;11(4):369-373. doi:10.1515/dx-2024-0008.
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psnet.ahrq.gov/node/46757/psn-pdf
February 07, 2018 - Practical application of high-reliability principles in
healthcare to optimize quality and safety outcomes.
February 7, 2018
Oster CA, Deakins S. Practical Application of High-Reliability Principles in Healthcare to Optimize Quality
and Safety Outcomes. J Nurs Admin. 2017;48(1):50-55. doi:10.1097/nna.00000000000005…
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psnet.ahrq.gov/node/46671/psn-pdf
June 25, 2018 - Twelve tips for embedding human factors and
ergonomics principles in healthcare education.
June 25, 2018
Vosper H, Hignett S, Bowie P. Twelve tips for embedding human factors and ergonomics principles in
healthcare education. Med Teach. 2017;40(4):357-363. doi:10.1080/0142159x.2017.1387240.
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psnet.ahrq.gov/node/47029/psn-pdf
August 15, 2018 - Peer support in anesthesia: turning war stories into
wellness.
August 15, 2018
Vinson AE, Randel G. Peer support in anesthesia: turning war stories into wellness. Curr Opin
Anaesthesiol. 2018;31(3):382-387. doi:10.1097/ACO.0000000000000591.
https://psnet.ahrq.gov/issue/peer-support-anesthesia-turning-war-stories-w…
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psnet.ahrq.gov/node/36494/psn-pdf
August 29, 2016 - Medication prescribing errors involving the route of
administration.
August 29, 2016
Lesar TS. Medication Prescribing Errors Involving the Route of Administration. Hosp Pharm.
2010;41(11):1053-1066. doi:10.1310/hpj4111-1053.
https://psnet.ahrq.gov/issue/medication-prescribing-errors-involving-route-administration
…
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psnet.ahrq.gov/node/866966/psn-pdf
October 16, 2024 - Diagnostic Excellence in U.S. Rural Healthcare: A Call to
Action.
October 16, 2024
Ali KJ, Galvez NJ, Craig S, et al. Diagnostic Excellence In U.s. Rural Healthcare: A Call To Action.
Rockville, MD: Agency for Healthcare Research and Quality; September 2024. AHRQ Publication No. 24-
0010-9-EF
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psnet.ahrq.gov/node/72773/psn-pdf
February 24, 2021 - Flow accuracy of IV smart pumps outside of patient
rooms during COVID-19.
February 24, 2021
Blake JWC, Giuliano KK. Flow accuracy of IV smart pumps outside of patient rooms during COVID-19.
AACN Adv Crit Care. 2020;31(4):357-363. doi:10.4037/aacnacc2020241.
https://psnet.ahrq.gov/issue/flow-accuracy-iv-smart-pumps…
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psnet.ahrq.gov/node/46393/psn-pdf
September 06, 2017 - The role of South--North partnerships in promoting
shared learning and knowledge transfer.
September 6, 2017
Basu L, Pronovost P, Molello NE, et al. The role of South-North partnerships in promoting shared learning
and knowledge transfer. Global Health. 2017;13(1):64. doi:10.1186/s12992-017-0289-6.
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psnet.ahrq.gov/node/46978/psn-pdf
April 04, 2018 - Using the patient safety huddle as a tool for high
reliability.
April 4, 2018
Brass SD, Olney G, Glimp R, et al. Using the Patient Safety Huddle as a Tool for High Reliability. Jt Comm
J Qual Patient Saf. 2018;44(4):219-226. doi:10.1016/j.jcjq.2017.10.004.
https://psnet.ahrq.gov/issue/using-patient-safety-huddle-t…
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psnet.ahrq.gov/node/45609/psn-pdf
November 16, 2016 - A review of healthcare failure mode and effects analysis
(HFMEA) in radiotherapy.
November 16, 2016
Giardina M, Cantone MC, Tomarchio E, et al. A Review of Healthcare Failure Mode and Effects Analysis
(HFMEA) in Radiotherapy. Health Phys. 2016;111(4):317-26. doi:10.1097/HP.0000000000000536.
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psnet.ahrq.gov/node/43024/psn-pdf
March 05, 2014 - Speaking up for patient safety by hospital-based health
care professionals: a literature review.
March 5, 2014
Okuyama A, Wagner C, Bijnen B. Speaking up for patient safety by hospital-based health care
professionals: a literature review. BMC Health Serv Res. 2014;14:61. doi:10.1186/1472-6963-14-61.
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February 15, 2023 - Medication mix-up: what happened at Vanderbilt and how
it impacts health care providers.
February 15, 2023
Michel C, Talley C. J Health Life Sci Law. 2022;17(1):71
https://psnet.ahrq.gov/issue/medication-mix-what-happened-vanderbilt-and-how-it-impacts-health-care-
providers
High-profile medication errors like tha…
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psnet.ahrq.gov/training-catalog/ihi-patient-safety-and-quality-emerging-leaders
March 03, 2025 - IHI Patient Safety and Quality for Emerging Leaders
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Organization:
Organization
Institute for Healthcare Improvement (IHI)
…
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psnet.ahrq.gov/node/47235/psn-pdf
July 11, 2018 - Safety, performance, and satisfaction outcomes in the
operating room: a literature review.
July 11, 2018
Joseph A, Bayramzadeh S, Zamani Z, et al. Safety, Performance, and Satisfaction Outcomes in the
Operating Room: A Literature Review. HERD. 2018;11(2):137-150. doi:10.1177/1937586717705107.
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psnet.ahrq.gov/node/45298/psn-pdf
April 22, 2017 - The problem with root cause analysis.
April 22, 2017
Peerally MF, Carr S, Waring J, et al. The problem with root cause analysis. BMJ Qual Saf. 2017;26(5):417-
422. doi:10.1136/bmjqs-2016-005511.
https://psnet.ahrq.gov/issue/problem-root-cause-analysis
Root cause analysis (RCA) is a strategy to investigate incident…
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psnet.ahrq.gov/node/44821/psn-pdf
December 05, 2022 - Action Planning Tool for the AHRQ Surveys on Patient
Safety Culture.
December 5, 2022
Yount N, Edelman S, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; November
2022. AHRQ Publication No. 23-0011.
https://psnet.ahrq.gov/issue/action-planning-tool-ahrq-surveys-patient-safety-culture
Im…
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psnet.ahrq.gov/node/35227/psn-pdf
June 15, 2011 - Building a Better Delivery System: A New
Engineering/Health Care Partnership.
June 15, 2011
Reid PP, Compton WD, Grossman JH, Fanjiang G, eds. Institute of Medicine, National Academy of
Engineering, Committee on Engineering and the Health Care System. Washington, DC: National
Academies Press; 2005. ISBN-10: 030909…