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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45414/psn-pdf
    August 17, 2016 - The next wave of hospital innovation to make patients safer. August 17, 2016 Ghaferi AA; Myers C; Sutcliffe KM; Pronovost PJ. https://psnet.ahrq.gov/issue/next-wave-hospital-innovation-make-patients-safer Achieving high reliability is a recognized goal for health care organizations. Reviewing current technical and…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50663/psn-pdf
    November 13, 2019 - Investigation into Electronic Prescribing and Medicines Administration Systems and Safe Discharge. November 13, 2019 Farnborough, UK: Healthcare Safety Investigation Branch; October 2019. https://psnet.ahrq.gov/issue/investigation-electronic-prescribing-and-medicines-administration-systems- and-safe-discharge Des…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45226/psn-pdf
    January 04, 2017 - AHRQ Research Summit on Improving Diagnosis in Health Care. January 4, 2017 Rockville, MD; Agency for Healthcare Research and Quality: September 28, 2016. https://psnet.ahrq.gov/issue/ahrq-research-summit-improving-diagnosis-health-care Research is increasingly focusing on diagnostic errors and strategies to reduc…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46039/psn-pdf
    April 05, 2017 - Retained lumbar catheter tip. April 5, 2017 DeLancey JO, Barnard C, Bilimoria KY. Retained Lumbar Catheter Tip. JAMA. 2017;317(12):1269-1270. doi:10.1001/jama.2017.1713. https://psnet.ahrq.gov/issue/retained-lumbar-catheter-tip Retained surgical items are considered a sentinel event. Discussing an incident involvi…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865819/psn-pdf
    May 08, 2024 - Focus on HARM (Harmonizing Accountability in Reporting and Monitoring). May 8, 2024 National Quality Forum. https://psnet.ahrq.gov/issue/focus-harm-harmonizing-accountability-reporting-and-monitoring Strong incident reporting systems are a foundational component for understanding preventable health care error. Th…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42330/psn-pdf
    June 12, 2013 - Creating a culture of safety in the emergency department: the value of teamwork training. June 12, 2013 Jones F, Podila P, Powers C. Creating a culture of safety in the emergency department: the value of teamwork training. J Nurs Adm. 2013;43(4):194-200. doi:10.1097/NNA.0b013e31828958cd. https://psnet.ahrq.gov/iss…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46708/psn-pdf
    February 08, 2023 - FDA/ISMP Safe Medication Management Fellowship Program. February 8, 2023 Food and Drug Administration, Institute for Safe Medication Practices. https://psnet.ahrq.gov/issue/fdaismp-safe-medication-management-fellowship-program This fellowship program provides clinicians with learning opportunities at the Institute…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42765/psn-pdf
    November 30, 2016 - Advancing Patient Safety Implementation Through Safe Medication Use Research (R18). November 30, 2016 Rockville, MD: Agency for Healthcare Research and Quality. PA-14-002. https://psnet.ahrq.gov/issue/advancing-patient-safety-implementation-through-safe-medication-use- research-r18 This funding program will suppo…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39609/psn-pdf
    June 27, 2010 - Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit. June 27, 2010 Papadopoulos J, Kane-Gill SL, Cooper B, eds. Crit Care Med. 2010;38:(suppl 6):S83-S264.   https://psnet.ahrq.gov/issue/identification-and-prevention-common-adverse-drug-events-intensive-care-unit This supplem…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48183/psn-pdf
    August 07, 2019 - Get the Medications Right Institute. August 7, 2019 8230 Old Courthouse Road, Suite 420, Tysons Corner, VA. https://psnet.ahrq.gov/issue/get-medications-right-institute A comprehensive systems-focused approach must be employed in the hospital and at home to ensure reliable medication use. This institute supports m…
  11. digital.ahrq.gov/ahrq-funded-projects/success-stories/text-messaging-managing-chronic-disease
    January 01, 2023 - Text Messaging for Managing Chronic Disease Your browser does not support inline frames. Please go to http://youtu.be/bpP8xawfoi4 to view the video. Principal Investigator: Jennifer Uhrig (Contract No. HHSA290200600001I #7) [5 min., 10 sec.] This project showed that text messaging can effec…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39020/psn-pdf
    October 14, 2009 - A critical review of the systems approach within patient safety research. October 14, 2009 Waterson P. A critical review of the systems approach within patient safety research. Ergonomics. 2009;52(10):1185-1195. doi:10.1080/00140130903042782. https://psnet.ahrq.gov/issue/critical-review-systems-approach-within-pat…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41009/psn-pdf
    December 21, 2011 - Improving ambulatory patient safety: learning from the last decade, moving ahead in the next. December 21, 2011 Wynia MK, Classen DC. Improving Ambulatory Patient Safety. JAMA. 2011;306(22):2504-2505. doi:10.1001/jama.2011.1820. https://psnet.ahrq.gov/issue/improving-ambulatory-patient-safety-learning-last-decade-…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72863/psn-pdf
    March 17, 2021 - 7 ways to prevent medical errors. March 17, 2021 Caceres V. US News World Report. March 1, 2021. https://psnet.ahrq.gov/issue/7-ways-prevent-medical-errors Patients and families have an important role in reducing potential for error and harm. This article highlights a set of tactics for patients to enhan…
  15. www.ahrq.gov/nursing-home/index.html
    Nursing Home COVID-19 Action Network About AHRQ's Nursing Home Network The network provides free training and mentorship to nursing homes across the country. 5-Minute Learn…
  16. digital.ahrq.gov/ahrq-funded-projects/enhancing-patient-matching-support-operational-health-information-exchange/citation/incorporating
    January 01, 2023 - Incorporating conditional dependence in latent class models for probabilistic record linkage: Does it matter?. Citation Huiping Xu. Xiaochun Li. Changyu Shen. Siu L. Hui. Shaun Grannis. "Incorporating conditional dependence in latent class models for probabilistic record linkage: Does it matter?." Ann…
  17. digital.ahrq.gov/ahrq-funded-projects/enhancing-patient-matching-support-operational-health-information-exchange/citation/data
    January 01, 2023 - The data-adaptive Fellegi-Sunter model for probabilistic record linkage: Algorithm development and validation for incorporating missing data and field selection. Citation Li X, Xu H, Grannis S. The data-adaptive Fellegi-Sunter model for probabilistic record linkage: Algorithm development and validatio…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39384/psn-pdf
    March 24, 2010 - Keeping safety a priority in home care and hospice: one agency's journey. March 24, 2010 Mullin LV. Keeping safety a priority in home care and hospice: one agency's journey. Home Healthc Nurse. 2010;28(2):63-70. doi:10.1097/NHH.0b013e3181cb5939. https://psnet.ahrq.gov/issue/keeping-safety-priority-home-care-and-ho…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39781/psn-pdf
    November 23, 2016 - Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. November 23, 2016 Oakbrook Terrace, IL: The Joint Commission; 2010. https://psnet.ahrq.gov/issue/advancing-effective-communication-cultural-competence-and-patient-and- family-centered-care This…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43920/psn-pdf
    July 10, 2018 - Master of Science in Medical and Healthcare Simulation. July 10, 2018 Drexel University College of Medicine. https://psnet.ahrq.gov/issue/master-science-medical-and-healthcare-simulation Simulation training enables learning from mistakes without the potential for patient harm. This multidisciplinary degree program…