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psnet.ahrq.gov/node/38267/psn-pdf
December 03, 2008 - National Priorities and Goals: Aligning Our Efforts to
Transform America's Healthcare.
December 3, 2008
National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 1933875194.
https://psnet.ahrq.gov/issue/national-priorities-and-goals-aligning-our-efforts-transform-americas-healthcare
This…
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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - In an effort to address this, a qualitative study using simulation videos reported on various barriers
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psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
April 27, 2022 - The least preferred language includes reference to the amount of effort required to take the medication
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - that minimizes the risk of mistakes. 4 Preventing medication errors in anesthesia demands a concerted effort
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psnet.ahrq.gov/web-mm/room-without-orders
September 01, 2011 - SPOTLIGHT CASE
A Room Without Orders
Citation Text:
Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/perspective/conversation-maureen-bisognano
February 26, 2025 - In Conversation With… Maureen Bisognano
June 1, 2015
Citation Text:
In Conversation With… Maureen Bisognano. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - SPOTLIGHT CASE
Too Many Cooks in the Kitchen
Citation Text:
Dutton RP. Too Many Cooks in the Kitchen. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
August 02, 2015 - SPOTLIGHT CASE
Despite Clues, Failed to Rescue
Citation Text:
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
March 01, 2018 - SPOTLIGHT CASE
Difficult Encounters: A CMO and CNO Respond
Citation Text:
Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/node/39419/psn-pdf
September 20, 2011 - Engaging patients as vigilant partners in safety: a
systematic review.
September 20, 2011
Schwappach DLB. Engaging patients as vigilant partners in safety: a systematic review. Med Care Res
Rev. 2010;67(2):119-148. doi:10.1177/1077558709342254.
https://psnet.ahrq.gov/issue/engaging-patients-vigilant-partners-safet…
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psnet.ahrq.gov/issue/patients-patient-safety-us
June 02, 2020 - Multi-use Website
Patients for Patient Safety US.
Citation Text:
Patients for Patient Safety US. 404.510.8787; info@pfps.us
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psnet.ahrq.gov/node/46233/psn-pdf
September 24, 2017 - Cutting-edge efforts in surgical patient safety.
September 24, 2017
Varghese TK, Ghaferi AA. Cutting-edge Efforts in Surgical Patient Safety. JAMA Surg. 2017;152(8):719-
720. doi:10.1001/jamasurg.2017.0858.
https://psnet.ahrq.gov/issue/cutting-edge-efforts-surgical-patient-safety
Implementation science examines me…
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psnet.ahrq.gov/node/43773/psn-pdf
May 01, 2015 - Efforts To Improve Patient Safety Result in 1.3 Million
Fewer Patient Harms: Interim Update on 2013 Annual
Hospital-Acquired Condition Rate and Estimates of Cost
Savings and Deaths Averted From 2010 to 2013.
May 1, 2015
Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. …
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psnet.ahrq.gov/node/34659/psn-pdf
April 07, 2010 - Leading change: why transformation efforts fail.
April 7, 2010
Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail
Kotter, a professor at Harvard Business School, outlines the eight stages of a successful change process,
as well a…
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psnet.ahrq.gov/node/42774/psn-pdf
May 28, 2015 - Patient safety in plastic surgery: identifying areas for
quality improvement efforts.
May 28, 2015
Hernandez-Boussard T, McDonald KM, Rhoads KF, et al. Patient safety in plastic surgery: identifying areas
for quality improvement efforts. Ann Plast Surg. 2015;74(5):597-602.
doi:10.1097/SAP.0b013e318297791e.
https:…
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psnet.ahrq.gov/node/73151/psn-pdf
April 14, 2021 - Could Efforts to Fight the Coronavirus Lead to Overuse of
Antibiotics?
April 14, 2021
Issue Brief. Washington DC: Pew Charitable Trust; March 2021.
https://psnet.ahrq.gov/issue/could-efforts-fight-coronavirus-lead-overuse-antibiotics
Antibiotic overuse is a contributor to nosocomial infection. This report discusse…
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psnet.ahrq.gov/node/837707/psn-pdf
July 20, 2022 - Who killed patient safety?
July 20, 2022
Hemmelgarn C, Hatlie MJ, Sheridan S, et al. Who killed patient safety? J Patient Saf Risk Manage.
2022;27(2):56-58. doi:10.1177/25160435221077778.
https://psnet.ahrq.gov/issue/who-killed-patient-safety
This commentary, authored by patients and families who have experienced …
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psnet.ahrq.gov/node/46892/psn-pdf
June 13, 2018 - AHRQ National Scorecard on Hospital-Acquired
Conditions Updated Baseline Rates and Preliminary
Results 2014–2016.
June 13, 2018
Rockville, MD: Agency for Healthcare Research and Quality; June 2018.
https://psnet.ahrq.gov/issue/ahrq-national-scorecard-hospital-acquired-conditions-updated-baseline-rates-
and-prelim…
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psnet.ahrq.gov/node/41821/psn-pdf
November 07, 2012 - Death of a boy prompts new medical efforts nationwide.
November 7, 2012
Dwyer J. New York Times. October 25, 2012.
https://psnet.ahrq.gov/issue/death-boy-prompts-new-medical-efforts-nationwide
Reporting on the death of a boy due to a missed diagnosis of infection, this newspaper article discusses
solutions being a…
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psnet.ahrq.gov/node/45769/psn-pdf
December 21, 2016 - National Scorecard on Rates of Hospital-Acquired
Conditions 2010 to 2015: Interim Data From National
Efforts to Make Health Care Safer.
December 21, 2016
Rockville, MD: Agency for Healthcare Research and Quality; December 2016.
https://psnet.ahrq.gov/issue/national-scorecard-rates-hospital-acquired-conditions-2010…