-
psnet.ahrq.gov/node/47003/psn-pdf
July 18, 2018 - Impact of an antiretroviral stewardship strategy on
medication error rates.
July 18, 2018
Shea KM, Hobbs AL, Shumake JD, et al. Impact of an antiretroviral stewardship strategy on medication
error rates. Am J Health Syst Pharm. 2018;75(12):876-885. doi:10.2146/ajhp170420.
https://psnet.ahrq.gov/issue/impact-antire…
-
psnet.ahrq.gov/node/43778/psn-pdf
April 22, 2015 - Meet the cancer patient in room 52: his name is Joseph,
but call him Joe.
April 22, 2015
Sun LH.
https://psnet.ahrq.gov/issue/meet-cancer-patient-room-52-his-name-joseph-call-him-joe
This newspaper article reports on a pilot program which involved redesigning intensive care unit processes
to enhance staff knowled…
-
psnet.ahrq.gov/node/43335/psn-pdf
July 09, 2014 - Wake Up Safe and root cause analysis: quality
improvement in pediatric anesthesia.
July 9, 2014
Tjia I, Rampersad S, Varughese AM, et al. Wake Up Safe and root cause analysis: quality improvement in
pediatric anesthesia. Anesth Analg. 2014;119(1):122-136. doi:10.1213/ANE.0000000000000266.
https://psnet.ahrq.gov/is…
-
psnet.ahrq.gov/node/36615/psn-pdf
January 14, 2011 - The Patient Safety and Quality Improvement Act of 2005:
provisions and potential opportunities.
January 14, 2011
Liang BA, Riley W, Rutherford W, et al. The Patient Safety and Quality Improvement Act of 2005:
Provisions and Potential Opportunities. American Journal of Medical Quality. 2007;22(1).
doi:10.1177/10628…
-
psnet.ahrq.gov/node/46192/psn-pdf
June 07, 2017 - Investigating the causes of adverse events.
June 7, 2017
Sanchez JA, Lobdell KW, Moffatt-Bruce SD, et al. Investigating the Causes of Adverse Events. Ann Thorac
Surg. 2017;103(6):1693-1699. doi:10.1016/j.athoracsur.2017.04.001.
https://psnet.ahrq.gov/issue/investigating-causes-adverse-events
Incident analysis enab…
-
psnet.ahrq.gov/node/42976/psn-pdf
May 29, 2014 - Quality and safety in pediatric hematology/oncology.
May 29, 2014
Mueller BU. Quality and safety in pediatric hematology/oncology. Pediatr Blood Cancer. 2014;61(6):966-9.
doi:10.1002/pbc.24946.
https://psnet.ahrq.gov/issue/quality-and-safety-pediatric-hematologyoncology
Children with cancer are particularly vulner…
-
psnet.ahrq.gov/node/39374/psn-pdf
March 17, 2010 - Bridging the gap: leveraging business intelligence tools
in support of patient safety and financial effectiveness.
March 17, 2010
Ferranti JM, Langman MK, Tanaka D, et al. Bridging the gap: leveraging business intelligence tools in
support of patient safety and financial effectiveness. J Am Med Inform Assoc. 2010;1…
-
psnet.ahrq.gov/node/46043/psn-pdf
April 05, 2017 - High-reliability and the I-PASS communication tool.
April 5, 2017
Clements K. High-reliability and the I-PASS communication tool. Nursing Management (Springhouse).
2017;48(3). doi:10.1097/01.numa.0000512897.68425.e5.
https://psnet.ahrq.gov/issue/high-reliability-and-i-pass-communication-tool
High reliability has y…
-
psnet.ahrq.gov/node/43057/psn-pdf
January 01, 2015 - Health care huddles: managing complexity to achieve
high reliability.
December 12, 2014
Provost SM, Lanham H, Leykum LK, et al. Health care huddles: managing complexity to achieve high
reliability. Health Care Manage Rev. 2015;40(1):2-12. doi:10.1097/HMR.0000000000000009.
https://psnet.ahrq.gov/issue/health-care-h…
-
psnet.ahrq.gov/node/60695/psn-pdf
July 15, 2020 - The coronavirus pandemic’s wider health-care crisis.
July 15, 2020
Khullar D. The coronavirus pandemic’s wider health-care crisis. New Yorker. 2020;Jun 29.
https://psnet.ahrq.gov/issue/coronavirus-pandemics-wider-health-care-crisis
The COVID-19 crisis has disrupted care delivery around the globe. This story discuss…
-
psnet.ahrq.gov/node/44144/psn-pdf
May 27, 2015 - Maintaining safety in the dialysis facility.
May 27, 2015
Kliger AS. Maintaining safety in the dialysis facility. Clin J Am Soc Nephrol. 2015;10(4):688-95.
doi:10.2215/CJN.08960914.
https://psnet.ahrq.gov/issue/maintaining-safety-dialysis-facility
Failure to consider human factors and poor communication can contri…
-
psnet.ahrq.gov/node/45549/psn-pdf
October 12, 2016 - Preventing diagnostic errors in primary care.
October 12, 2016
Ely JW, Graber ML. Preventing Diagnostic Errors in Primary Care. Am Fam Physician. 2016;94(6):426-32.
https://psnet.ahrq.gov/issue/preventing-diagnostic-errors-primary-care
The Improving Diagnosis in Health Care report advocated for enhancing patient en…
-
psnet.ahrq.gov/node/73354/psn-pdf
June 02, 2021 - Advancing Maternal Health Equity and Reducing Maternal
Mortality Workshop.
June 2, 2021
National Academies of Sciences, Engineering, and Medicine. June 7-8, 2021.
https://psnet.ahrq.gov/issue/advancing-maternal-health-equity-and-reducing-maternal-mortality-workshop
Maternal safety is challenged by clinical, equity…
-
psnet.ahrq.gov/node/35375/psn-pdf
January 02, 2017 - Integrating the intensive care unit safety reporting system
with existing incident reporting systems.
January 2, 2017
Thompson DA, Lubomski LH, Holzmueller CG, et al. Integrating the intensive care unit safety reporting
system with existing incident reporting systems. Jt Comm J Qual Patient Saf. 2005;31(10):585-93.…
-
psnet.ahrq.gov/node/48182/psn-pdf
August 21, 2019 - Organizational learning in hospitals: a realist review.
August 21, 2019
Lyman B, Jacobs JD, Hammond EL, et al. Organizational learning in hospitals: A realist review. J Adv Nurs.
2019;75(11):2352-2377. doi:10.1111/jan.14091.
https://psnet.ahrq.gov/issue/organizational-learning-hospitals-realist-review
Organization…
-
psnet.ahrq.gov/node/838639/psn-pdf
October 19, 2022 - Calibrate Dx: A Resource to Improve Diagnostic
Decisions.
October 19, 2022
Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication no. 22(23)-
0047-2-EF.
https://psnet.ahrq.gov/issue/calibrate-dx-resource-improve-diagnostic-decisions
Delayed, wrong, and missed diagnoses are commo…
-
psnet.ahrq.gov/node/48167/psn-pdf
August 28, 2019 - ASHP guidelines on perioperative pharmacy services.
August 28, 2019
Bickham P, Golembiewski J, Meyer T, et al. ASHP guidelines on perioperative pharmacy services. Am J
Health Syst Pharm. 2019;76(12):903-820. doi:10.1093/ajhp/zxz073.
https://psnet.ahrq.gov/issue/ashp-guidelines-perioperative-pharmacy-services
Pharm…
-
psnet.ahrq.gov/node/44488/psn-pdf
September 16, 2015 - Environmental Cleaning for the Prevention of Healthcare-
Associated Infections (HAIs).
September 16, 2015
Leas BF, Sullivan N, Han JH, Pegues DA, Kaczmarek JL, Umscheid CA. Rockville, MD: Agency for
Healthcare Research and Quality; August 2015. Technical Brief No. 22. AHRQ Publication No. 15-
EHC020-EF.
https://p…
-
psnet.ahrq.gov/node/45223/psn-pdf
September 27, 2017 - Hospital safety climate and safety behavior: a social
exchange perspective.
September 27, 2017
Ancarani A, Di Mauro C, Giammanco MD. Hospital safety climate and safety behavior: A social exchange
perspective. Health Care Manage Rev. 2017;42(4):341-351. doi:10.1097/HMR.0000000000000118.
https://psnet.ahrq.gov/issue…
-
psnet.ahrq.gov/node/39572/psn-pdf
January 03, 2017 - The tangible handoff: a team approach for advancing
structured communication in labor and delivery.
January 3, 2017
Block M, Ehrenworth JF, Cuce VM, et al. The tangible handoff: a team approach for advancing structured
communication in labor and delivery. Jt Comm J Qual Patient Saf. 2010;36(6):282-287, 241.
https:…