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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - Annual Perspective
Ensuring Patient and Workforce Safety Culture in Healthcare
John Murray, Joann Sorra, Bryan Gale, Sarah Mossburg
| March 27, 2024
View more articles from the same authors.
Citation Text:
Murray J, Sorra J, Gale B, et al. Ensuring Patient…
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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an
Order is Not Enough
April 28, 2021
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
Disclosure of Relev…
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psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
November 01, 2016 - SPOTLIGHT CASE
Dying in the Hospital With Advanced Dementia
Citation Text:
Umscheid CA, McGreevey JD, Greysen RS. Dying in the Hospital With Advanced Dementia. 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/sites/default/files/2022-08/final_spotlight_latex_allergies-slides.pdf
January 01, 2022 - Spotlight
Spotlight
Perioperative Anaphylaxis After Insertion of
a Latex Drain in a Patient with Known Latex
Allergy
Source and Credits
• This presentation is based on the August 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by K…
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psnet.ahrq.gov/node/867653/psn-pdf
February 26, 2025 - In Conversation with Jessica Behrhorst about The
Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. In Conversation with Jessica Behrhorst about The Evolution of Root Cause
Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evoluti…
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psnet.ahrq.gov/node/857061/psn-pdf
November 27, 2023 - In Conversation with... Joan Stanley about The Role of
Undergraduate Nursing Education in Patient Safety
November 27, 2023
Stanley J. In Conversation with.. Joan Stanley about The Role of Undergraduate Nursing Education in
Patient Safety . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-joa…
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psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
September 18, 2024 - SPOTLIGHT CASE
Diagnostic Delay in the Emergency Department
Citation Text:
Marshall K, Singh H. Diagnostic Delay in the Emergency Department. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:…
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psnet.ahrq.gov/node/74178/psn-pdf
December 15, 2021 - Strategies to Improve Patient Safety: Final Report to
Congress Required by the Patient Safety and Quality
Improvement Act of 2005.
December 15, 2021
Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-
0009.
https://psnet.ahrq.gov/issue/strategies-improve-patient-safe…
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psnet.ahrq.gov/node/39195/psn-pdf
January 28, 2010 - Lack of patient knowledge regarding hospital
medications.
January 28, 2010
Lack of patient knowledge regarding hospital medications.
https://psnet.ahrq.gov/issue/lack-patient-knowledge-regarding-hospital-medications
The Joint Commission requires that hospitals encourage patients' involvement in their own safety as…
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psnet.ahrq.gov/node/35220/psn-pdf
May 14, 2015 - Patient Safety and Quality Improvement Act of 2005.
May 14, 2015
Pub L No. 109-41.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005
This bill amends the Public Health Service Act to encourage a culture of safety in health care organizations.
The bill, signed into law July 29, 2005…
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psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
August 01, 2010 - Incorporating patient safety into both the formal and informal curriculum has been encouraged since 2001
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psnet.ahrq.gov/node/36378/psn-pdf
October 28, 2010 - Teaching but not learning: how medical residency
programs handle errors.
October 28, 2010
Hoff T, Pohl H, Bartfield J. Teaching but not learning: how medical residency programs handle errors. J
Organ Behav. 2006;27(7). doi:10.1002/job.395.
https://psnet.ahrq.gov/issue/teaching-not-learning-how-medical-residency-pr…
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psnet.ahrq.gov/issue/encouraging-employees-speak-prevent-infections-opportunities-leverage-quality-improvement-and
January 23, 2017 - Study
Encouraging employees to speak up to prevent infections: opportunities to leverage quality improvement and care management processes.
Citation Text:
Robbins J, McAlearney AS. Encouraging employees to speak up to prevent infections: Opportunities to leverage quality improvement and …
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psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
April 08, 2019 - Our care delivery processes have neither encouraged nor facilitated data sharing, in part because we've
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psnet.ahrq.gov/web-mm/pill-organizing-plight
June 19, 2018 - The top patient safety strategies that can be encouraged for adoption now.
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psnet.ahrq.gov/node/866261/psn-pdf
July 10, 2024 - Every team member should be encouraged to speak up and voice any concerns about the
patient’s position
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - Institutions are encouraged to create policies and procedures that allow for second-level review and/
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psnet.ahrq.gov/node/60000
January 01, 2021 - Patient Safety Innovations Exchange
The Patient Safety Innovations Exchange highlights important innovations that can lead to improvements in patient safety. It is based on AHRQ’s Health Care Innovations Exchange , which shares many health care innovations, including those that improve patient safety. While available …
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psnet.ahrq.gov/issue/brief-american-hospital-association-and-federation-american-hospitals-amici-curiae-supporting
October 24, 2022 - Legislation/Case Law
Brief for the American Hospital Association and Federation of American Hospitals as Amici Curiae Supporting Respondents, Southern Baptist Hospital of Florida, Inc. v. Jean Charles, Jr. No. 16-1446. July 6, 2017.
Citation Text:
American Hospital Association and Federa…
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psnet.ahrq.gov/issue/ohio-patient-safety-institute-opsi
January 08, 2020 - Multi-use Website
Ohio Patient Safety Institute.
Citation Text:
Ohio Hospital Association, 155 East Broad St, Suite 301, Columbus, OH 43215-3620.
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