-
psnet.ahrq.gov/node/73408/psn-pdf
July 27, 2023 - Patient Safety/Quality Improvement Primer.
July 27, 2023
Otolaryngol Head Neck Surg. 2018-2023.
https://psnet.ahrq.gov/issue/patient-safetyquality-improvement-primer
Otolaryngology-head and neck surgery is vulnerable to wrong site errors and other challenges present in
surgical care. This series of articles highli…
-
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/worksheet.html
July 01, 2023 - Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership
AHRQ Safety Program for Perinatal Care
Purpose: To enhance communication and shared problem solving between clinical staff and senior executives with respect to patient safety issues on the labor and delivery unit.
…
-
psnet.ahrq.gov/node/39435/psn-pdf
April 07, 2010 - Patient safety in surgery: non-technical aspects of safe
surgical performance.
April 7, 2010
Youngson GG, Flin R. Patient safety in surgery: non-technical aspects of safe surgical performance.
Patient Saf Surg. 2010;4(1):4. doi:10.1186/1754-9493-4-4.
https://psnet.ahrq.gov/issue/patient-safety-surgery-non-technica…
-
psnet.ahrq.gov/node/841198/psn-pdf
December 07, 2022 - Technology, Education and Safety.
December 7, 2022
Arna D, ed. Curr Opin Anaesthesiol. 2022;35(6):710-737.
https://psnet.ahrq.gov/issue/technology-education-and-safety-1
Safety challenges in anesthesiology and perioperative care are high-risk situations. This segment of a
reoccurring special section covers strateg…
-
digital.ahrq.gov/ahrq-funded-projects/enhancing-patient-matching-support-operational-health-information-exchange/citation/effect
January 01, 2023 - Evaluating the effect of data standardization and validation on patient matching accuracy.
Citation
Grannis SJ, Xu H, Vest JR, Kasthurirathne S, Bo N, Moscovitch B, Torkzadeh R, Rising J. Evaluating the effect of data standardization and validation on patient matching accuracy. J Am Med Inform Assoc. …
-
digital.ahrq.gov/ahrq-funded-projects/enhancing-patient-matching-support-operational-health-information-exchange/citation/evaluation
January 01, 2023 - Evaluation of real-world referential and probabilistic patient matching to advance patient identification strategy.
Citation
Grannis SJ, Williams JL, Kasthuri S, Murray M, Xu H. Evaluation of real-world referential and probabilistic patient matching to advance patient identification strategy. J Am Med…
-
psnet.ahrq.gov/node/43964/psn-pdf
November 25, 2015 - Simulation-based Surgical Education.
November 25, 2015
Surgery. 2015;158:1395-1440.
https://psnet.ahrq.gov/issue/simulation-based-surgical-education
Simulation training is widely accepted as a method to enhance operative techniques and nontechnical
behaviors. Articles in this special issue cover topics in surgical…
-
psnet.ahrq.gov/node/44137/psn-pdf
May 13, 2015 - AHRQ Patient Safety YouTube Channel.
May 13, 2015
Rockville, MD: Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/ahrq-patient-safety-youtube-channel
This Web site hosts a collection of training videos to highlight two improvement strategies: the
Comprehensive Unit-based Safety Program and …
-
psnet.ahrq.gov/node/42180/psn-pdf
April 22, 2013 - Building collaborative teams in neonatal intensive care.
April 22, 2013
Brodsky D, Gupta M, Quinn M, et al. Building collaborative teams in neonatal intensive care. BMJ Qual Saf.
2013;22(5):374-82. doi:10.1136/bmjqs-2012-000909.
https://psnet.ahrq.gov/issue/building-collaborative-teams-neonatal-intensive-care
An i…
-
psnet.ahrq.gov/node/44071/psn-pdf
November 16, 2015 - Quality Improvement in Neurosurgery.
November 16, 2015
Rolston JD, Han SJ, Parsa AT, eds. Neurosurg Clin N Am. 2015;26(2):143-322.
https://psnet.ahrq.gov/issue/quality-improvement-neurosurgery
This special issue covers elements of safe care delivery in neurosurgery and features articles exploring the
use of simula…
-
psnet.ahrq.gov/node/46824/psn-pdf
June 26, 2018 - Management reasoning: beyond the diagnosis.
June 26, 2018
Cook DA, Sherbino J, Durning SJ. Management Reasoning: Beyond the Diagnosis. JAMA.
2018;319(22):2267-2268. doi:10.1001/jama.2018.4385.
https://psnet.ahrq.gov/issue/management-reasoning-beyond-diagnosis
This commentary reviews five differences between diagno…
-
digital.ahrq.gov/ahrq-funded-projects/enhancing-providers-ability-followup-abnormal-test-results/citation/understanding
January 01, 2023 - Toward a better understanding of task demands, workload, and performance during physician-computer interactions.
Citation
Mazur LM, Mosaly PR, Moore C, et al. Toward a better understanding of task demands, workload, and performance during physician-computer interactions. J Am Med Inform Assoc 2016 Mov…
-
psnet.ahrq.gov/node/864868/psn-pdf
March 27, 2024 - Inpatient Transitions of Care: Challenges and Safety
Practices
March 27, 2024
Satake A, McElroy V. Inpatient Transitions of Care: Challenges and Safety Practices. PSNet [internet].
2024.
https://psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
Background
Transitions of care occur …
-
www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/dx-safety-workgroup-meeting-notes-apr2025.pdf
August 01, 2025 - Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare, April 18, 2025
Federal Interagency Workgroup:
Improving Diagnostic Safety and Quality in Healthcare
April 18, 2025, 10 AM–Noon
1
Workgroup Goal: Established by Senate Report 115-150. The Senate Committee on
Appropriation…
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-118-fullreport.pdf
October 01, 2016 - We employed a highly engaged process to develop an enhanced set of measures. … Two excellent measures proposed by The Vermont Oxford Network (VON) are complemented
and enhanced by … multidisciplinary expert panel who participated in a two-round
RAND/UCLA modified Delphi process, with enhanced … temperature measurement, and specific and meaningful temperature
cutoffs, were developed using an enhanced
-
psnet.ahrq.gov/node/45932/psn-pdf
May 18, 2017 - Polypharmacy.
May 18, 2017
Zagaria MAE, ed. Clin Geriatr Med. 2017;33:153-292.
https://psnet.ahrq.gov/issue/polypharmacy
Older patients are likely to be prescribed multiple medications, which can increase risks. Articles in this
special issue explore polypharmacy in a variety of care settings and provide tactics f…
-
digital.ahrq.gov/ahrq-funded-projects/patient-centered-informatics-system-enhance-health-care-rural-communities-0
January 01, 2023 - Psychometric assessment of the patient activation measure short form (PAM-13) in rural settings.
Citation
Hung M, Carter M, Hayden C, et al. Psychometric assessment of the patient activation measure short form (PAM-13) in rural settings. Qual Life Res 2013 Apr;22(3):521-9.
Link
http://www.ncbi…
-
psnet.ahrq.gov/node/837813/psn-pdf
January 21, 2021 - Recognizing Excellence in Diagnosis.
January 21, 2021
The Leapfrog Group.
https://psnet.ahrq.gov/issue/recognizing-excellence-diagnosis
Examination of diagnostic failure and identification of reduction strategies require multidisciplinary expertise
to be successful. This collaborative initiative will initially dev…
-
psnet.ahrq.gov/node/38452/psn-pdf
December 30, 2014 - The safety of intravenous drug delivery systems: update
on current issues since the 1999 Consensus Development
Conference.
December 30, 2014
Sanborn M, Gabay M, Moody ML. Hosp Pharm. 2009;44:159-164.
https://psnet.ahrq.gov/issue/safety-intravenous-drug-delivery-systems-update-current-issues-1999-
consensus-develo…
-
psnet.ahrq.gov/node/42521/psn-pdf
August 21, 2013 - Why your TeamSTEPPS program may not be working.
August 21, 2013
Clapper TC, Ng GM. Why Your TeamSTEPPS™ Program May Not Be Working. Clin Simul Nurs.
2012;9(8). doi:10.1016/j.ecns.2012.03.007.
https://psnet.ahrq.gov/issue/why-your-teamstepps-program-may-not-be-working
This commentary explores barriers to implementi…