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psnet.ahrq.gov/node/47440/psn-pdf
April 07, 2019 - Improving inpatient mental health medication safety
through the process of obtaining HIMSS Stage 7: a case
report.
April 7, 2019
Sulkers H, Tajirian T, Paterson J, et al. JAMIA Open. 2019;2:35–39.
https://psnet.ahrq.gov/issue/improving-inpatient-mental-health-medication-safety-through-process-
obtaining-himss-sta…
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psnet.ahrq.gov/node/44809/psn-pdf
March 02, 2016 - Seniors managing multiple medications: using mixed
methods to view the home care safety lens.
March 2, 2016
Lang A, Macdonald M, Marck P, et al. Seniors managing multiple medications: using mixed methods to
view the home care safety lens. BMC Health Serv Res. 2015;15:548. doi:10.1186/s12913-015-1193-5.
https://psn…
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psnet.ahrq.gov/node/46370/psn-pdf
November 08, 2017 - Standard admission order sets promote ordering of
unnecessary investigations: a quasi-randomised
evaluation in a simulated setting.
November 8, 2017
Leis B, Frost A, Bryce R, et al. Standard admission order sets promote ordering of unnecessary
investigations: a quasi-randomised evaluation in a simulated setting. B…
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psnet.ahrq.gov/node/44755/psn-pdf
November 18, 2016 - Effect of patient-centred bedside rounds on hospitalised
patients' decision control, activation and satisfaction with
care.
November 18, 2016
O'Leary KJ, Killarney A, Hansen LO, et al. Effect of patient-centred bedside rounds on hospitalised
patients' decision control, activation and satisfaction with care. BMJ Qu…
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psnet.ahrq.gov/node/837735/psn-pdf
July 27, 2022 - A quality improvement initiative using peer audit and
feedback to improve compliance with the surgical safety
checklist.
July 27, 2022
Fridrich A, Imhof A, Staender S, et al. A quality improvement initiative using peer audit and feedback to
improve compliance. Int J Qual Health Care. 2022;34(3). doi:10.1093/intqhc…
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psnet.ahrq.gov/node/73979/psn-pdf
January 01, 2022 - The work of nurses to provide good and safe services to
children receiving hospital-at-home: a qualitative
interview study from the perspectives of hospital nurses
and physicians.
October 20, 2021
Aasen L, Johannessen A?K, Ruud Knutsen I, et al. The work of nurses to provide good and safe services
to children rec…
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www.ahrq.gov/takeheart/beyond/million-hearts/index.html
November 01, 2022 - Million Hearts®
Million Hearts ® , a national initiative co-led by the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS) with the goal of preventing 1 million acute cardiovascular events by 2027, is working with cardiac rehabilitation (CR) professionals, pub…
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psnet.ahrq.gov/node/44688/psn-pdf
February 23, 2018 - Improving diagnosis in health care—the next imperative
for patient safety.
February 23, 2018
Singh H, Graber ML. Improving Diagnosis in Health Care--The Next Imperative for Patient Safety. New
Engl J Med. 2015;373(26):2493-2495. doi:10.1056/NEJMp1512241.
https://psnet.ahrq.gov/issue/improving-diagnosis-health-care…
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psnet.ahrq.gov/node/46372/psn-pdf
September 13, 2017 - Impact of a successful speaking up program on health-
care worker hand hygiene behavior.
September 13, 2017
Linam MW; Honeycutt MD; Gilliam CH; Wisdom CM; Deshpande JK.
https://psnet.ahrq.gov/issue/impact-successful-speaking-program-health-care-worker-hand-hygiene-
behavior
Improving hand hygiene in health care f…
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psnet.ahrq.gov/node/47034/psn-pdf
May 16, 2018 - Disruptive physician behavior: the importance of
recognition and intervention and its impact on patient
safety.
May 16, 2018
John PR, Heitt MC. Disruptive Physician Behavior: The Importance of Recognition and Intervention and Its
Impact on Patient Safety. J Hosp Med. 2018;13(3):210-212. doi:10.12788/jhm.2945.
htt…
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psnet.ahrq.gov/node/45159/psn-pdf
June 15, 2016 - Opioid abuse in chronic pain—misconceptions and
mitigation strategies.
June 15, 2016
Volkow ND, McLellan T. Opioid Abuse in Chronic Pain--Misconceptions and Mitigation Strategies. New
Engl J Med. 2016;374(13):1253-1263. doi:10.1056/NEJMra1507771.
https://psnet.ahrq.gov/issue/opioid-abuse-chronic-pain-misconception…
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psnet.ahrq.gov/node/44616/psn-pdf
November 04, 2015 - Development of "SWARM" as a model for high reliability,
rapid problem solving, and institutional learning.
November 4, 2015
Williams EA, Nikolai DA, Ladwig L, et al. Development of "SWARM" as a Model for High Reliability, Rapid
Problem Solving, and Institutional Learning. Jt Comm J Qual Patient Saf. 2015;41(11):508…
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psnet.ahrq.gov/node/73664/psn-pdf
September 01, 2021 - Chief resident indirect supervision in training safety
study: is a chief resident general surgery service safe for
patients?
September 1, 2021
Speaks L, Helmer SD, Quinn KR, et al. Chief resident indirect supervision in training safety study: is a chief
resident general surgery service safe for patients? J Surg Ed…
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psnet.ahrq.gov/node/836760/psn-pdf
March 16, 2022 - Comprehensive Healthcare Inspection Summary Report:
Evaluation of Mental Health in Veterans Health
Administration Facilities, Fiscal Year 2020.
March 16, 2022
Washington, DC: VA Office of the Inspector General; February 17, 2022. Report No. 21-01506-76.
https://psnet.ahrq.gov/issue/comprehensive-healthcare-i…
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psnet.ahrq.gov/node/46849/psn-pdf
May 23, 2018 - 1,300 days and counting: a risk model approach to
preventing retained foreign objects (RFOs).
May 23, 2018
Duggan EG, Fernandez J, Saulan MM, et al. 1,300 Days and Counting: A Risk Model Approach to
Preventing Retained Foreign Objects (RFOs). Jt Comm J Qual Patient Saf. 2018;44(5):260-269.
doi:10.1016/j.jcjq.2017.…
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psnet.ahrq.gov/node/45463/psn-pdf
April 12, 2017 - Implementation of the trigger review method in Scottish
general practices: patient safety outcomes and potential
for quality improvement.
April 12, 2017
de Wet C, Black C, Luty S, et al. Implementation of the trigger review method in Scottish general practices:
patient safety outcomes and potential for quality imp…
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psnet.ahrq.gov/node/46365/psn-pdf
September 06, 2017 - Learning to overcome hierarchical pressures to achieve
safer patient care: an interprofessional simulation for
nursing, medical, and physician assistant students.
September 6, 2017
Reeves SA, Denault D, Huntington JT, et al. Learning to Overcome Hierarchical Pressures to Achieve
Safer Patient Care: An Interprofess…
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psnet.ahrq.gov/node/47755/psn-pdf
July 24, 2019 - Animated stories of medical error as a means of teaching
undergraduates patient safety: an evaluation study.
July 24, 2019
Cooper K, Hatfield E, Yeomans J. Animated stories of medical error as a means of teaching
undergraduates patient safety: an evaluation study. Perspect Med Edu. 2019;8(2):118-122.
doi:10.1007/s…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-weaning.pdf
June 02, 2025 - NICU Family Information Packet, Appendix B, Weaning
Weaning
Description
■ The introduction of solid food feedings and the gradual replacement of milk by solid food as
the main source of energy and nutrients.
■ Shared pleasure in eating and feeding enhances the relationship between infants and their
caregivers.
…
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psnet.ahrq.gov/node/44257/psn-pdf
November 06, 2015 - A systems approach to evaluating ionizing radiation: six
focus areas to improve quality, efficiency, and patient
safety.
November 6, 2015
Perlin JB, Mower L, Bushe C. A systems approach to evaluating ionizing radiation: six focus areas to
improve quality, efficiency, and patient safety. J Healthc Qual. 2015;37(3):…