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psnet.ahrq.gov/node/44663/psn-pdf
September 27, 2016 - Impact of regionalized care on concordance of plan and
preventable adverse events on general medicine services.
September 27, 2016
Mueller SK, Schnipper JL, Giannelli K, et al. Impact of regionalized care on concordance of plan and
preventable adverse events on general medicine services. J Hosp Med. 2016;11(9):620-…
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psnet.ahrq.gov/node/43127/psn-pdf
April 23, 2014 - An interprofessional qualitative study of barriers and
potential solutions for the safe use of insulin in the
hospital setting.
April 23, 2014
Rousseau M-P, Beauchesne M-F, Naud A-S, et al. An interprofessional qualitative study of barriers and
potential solutions for the safe use of insulin in the hospital settin…
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psnet.ahrq.gov/node/44705/psn-pdf
January 01, 2017 - Team dynamics, clinical work satisfaction, and patient
care coordination between primary care providers: a
mixed methods study.
December 7, 2016
Song H, Ryan M, Tendulkar S, et al. Team dynamics, clinical work satisfaction, and patient care
coordination between primary care providers: A mixed methods study. Health…
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psnet.ahrq.gov/node/44801/psn-pdf
June 22, 2016 - Safety for all: integrated design for inpatient units.
June 22, 2016
Hunt JM, Sine DM. Patient Saf Qual Healthc. May/June 2016;13:20-28.
https://psnet.ahrq.gov/issue/safety-all-integrated-design-inpatient-units
Design is emerging as an important tactic to augment safe care delivery. Hospitals that provide care for
…
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psnet.ahrq.gov/node/74116/psn-pdf
November 24, 2021 - NCICLE Pathways to Excellence: Expectations for an
Optimal Clinical Learning Environment to Achieve Safe
and High-Quality Patient Care, 2021.
November 24, 2021
Chicago, IL: National Collaborative for Improving the Clinical Learning Environment; 2021. ISBN:
9781945365416.
https://psnet.ahrq.gov/issue/ncicle-pathwa…
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psnet.ahrq.gov/node/45499/psn-pdf
May 03, 2017 - Patient safety and interprofessional education: a report of
key issues from two interprofessional workshops.
May 3, 2017
Anderson ES, Gray R, Price K. Patient safety and interprofessional education: A report of key issues from
two interprofessional workshops. J Interprof Care. 2017;31(2):154-163.
doi:10.1080/13561…
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psnet.ahrq.gov/node/48062/psn-pdf
August 07, 2019 - Ten ways to improve medication safety in community
pharmacies.
August 7, 2019
Rupp MT. 10 ways to improve medication safety in community pharmacies. J Am Pharm Assoc (2003).
2019;59(4):474-478. doi:10.1016/j.japh.2019.03.018.
https://psnet.ahrq.gov/issue/ten-ways-improve-medication-safety-community-pharmacies
Med…
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psnet.ahrq.gov/node/45170/psn-pdf
August 03, 2016 - Radiologist-initiated double reading of abdominal CT:
retrospective analysis of the clinical importance of
changes to radiology reports.
August 3, 2016
Lauritzen PM, Andersen JG, Stokke MV, et al. Radiologist-initiated double reading of abdominal CT:
retrospective analysis of the clinical importance of changes to …
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psnet.ahrq.gov/node/45131/psn-pdf
July 20, 2016 - Systematic review and meta-analysis of educational
interventions designed to improve medication
administration skills and safety of registered nurses.
July 20, 2016
Härkänen M, Voutilainen A, Turunen E, et al. Systematic review and meta-analysis of educational
interventions designed to improve medication administr…
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psnet.ahrq.gov/node/867097/psn-pdf
November 06, 2024 - Recommendations but no Action: Improving the
Effectiveness of Quality and Safety Recommendations in
Healthcare.
November 6, 2024
Recommendations But No Action: Improving The Effectiveness Of Quality And Safety Recommendations
In Healthcare. Dorset, UK: Health Services Safety Investigations Body; September 2024.
h…
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digital.ahrq.gov/sites/default/files/docs/HealthITandUnderservedPopulations.pdf
September 17, 2010 - Keystone Beacon Community
Patient Outcomes
C
o
st
e
ff
ic
ie
n
cy
/
M
ar
ke
ta
b
le
Enhanced
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/cre.pdf
September 26, 2019 - hospital’s multi-faceted intervention included antibiotic
stewardship measures, contact isolation, and enhanced … Toth et al.,
201719
• Enhanced contact isolation
• Active surveillance
The model’s intervention … Active
surveillance and enhanced contact isolation were found to be successful in one model of LTACHs … high
Organism: CP-KP
Toth et al.,
201719
Mathematical
model that
measured the
effects of
enhanced … The enhanced isolation
model accounted for patients
contributing 75% less to
transmission rate compared
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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…
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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 …
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digital.ahrq.gov/sites/default/files/docs/medicaid/us_chs_states-role-in-hie.pdf
September 25, 2006 - fees for payors
• Originated by focusing on existing claims data information exchange
and slowly enhanced
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/pbrn/pbrn_technical_expert_panel_report_2025.pdf
January 01, 2025 - The members
offered insight into how the PBRN website and Registry can be enhanced for use by
PBRNs … Website content can be
enhanced. … made to the Registry:
· Updates to listings and contact information available within the Registry.
· Enhanced … Coley, Pharm.D.,
FCCP
Pharmacy Innovation
Network
PA 2018 Medium Implementation and
provision of enhanced
-
www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-3-implementation-guide.pdf
June 02, 2025 - workflow processes to accommodate changes necessary for the implementation
of automatic referral with enhanced
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www.ahrq.gov/sites/default/files/2025-05/fraser-dunagan-report.pdf
January 01, 2025 - SES was enhanced to include all types of patient safety events
and was expanded to other hospitals in
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/poster-4x6-delirium.pdf
June 01, 2021 - Identifying Delirium: ABCs of Identification_4x6
AHRQ Pub. No. 17(21)-0029
June 2021
IDENTIFYING DELIRIUM
ABCs OF IDENTIFICATION
Acute/subacute
• Altered mental status from baseline
Behavioral disturbance
• Restless, agitated, combative
Changes in consciousness
• Jittery, drowsy, difficult to aro…
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pso.ahrq.gov/faq/what-are-patient-safety-activities
SHARE:
What are "patient safety activities"?
There are eight patient safety activities that are carried out by, or on behalf of a PSO, or a healthcare provider:
Efforts to improve patient safety and the quality of healthcare delivery
The collection and ana…