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psnet.ahrq.gov/node/50633/psn-pdf
November 06, 2019 - Findings of Two Inaugural Leapfrog Surveys 2019.
November 6, 2019
Washington DC: Leapfrog Group; 2019.
https://psnet.ahrq.gov/issue/findings-two-inaugural-leapfrog-surveys-2019
Ambulatory surgery centers (ASC) are established venues for surgical care despite engagement in
assessment to ensure their safety. This re…
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psnet.ahrq.gov/issue/reducing-diagnostic-errors-why-now
July 28, 2014 - Commentary
Classic
Reducing diagnostic errors—why now?
Citation Text:
Khullar D, Jha AK, Jena AB. Reducing diagnostic errors--why now? N Engl J Med. 2015;373(26):2491-2493. doi:10.1056/NEJMp1508044.
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psnet.ahrq.gov/issue/reducing-health-care-hazards-lessons-commercial-aviation-safety-team
September 17, 2010 - Commentary
Reducing health care hazards: lessons from the Commercial Aviation Safety Team.
Citation Text:
Pronovost P, Goeschel CA, Olsen KL, et al. Reducing health care hazards: lessons from the commercial aviation safety team. Health Aff (Millwood). 2009;28(3):w479-89. doi:10.1377/hl…
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psnet.ahrq.gov/issue/national-action-plan-adverse-drug-event-prevention-recommendations-safer-outpatient-opioid
August 05, 2015 - Commentary
National Action Plan for Adverse Drug Event Prevention: recommendations for safer outpatient opioid use.
Citation Text:
Ducoffe AR, York A, Hu DJ, et al. National Action Plan for Adverse Drug Event Prevention: Recommendations for Safer Outpatient Opioid Use. Pain Med. 2016;17(…
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psnet.ahrq.gov/node/863224/psn-pdf
February 28, 2024 - Special Section: IEA Health Care 2021.
February 28, 2024
Hum Factors. 2024;66(3):633-769.
https://psnet.ahrq.gov/issue/special-section-iea-health-care-2021
The ergonomics community has an established interest in medical error reduction. The 2021 International
Ergonomics Association conference examined applications…
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psnet.ahrq.gov/node/38269/psn-pdf
October 01, 2024 - Nursing Home Survey on Patient Safety Culture.
October 1, 2024
Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
https://psnet.ahrq.gov/issue/nursing-home-survey-patient-safety-culture
Challenges to establishing and sustaining a safety culture in a nursing home include insufficient staffing
…
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psnet.ahrq.gov/node/866530/psn-pdf
August 14, 2024 - Healthcare Simulation in Nursing Practice.
August 14, 2024
Watts PI. Healthcare Simulation in Nursing Practice. Nurs Clin North Am. 2024;59(3):345-510.
https://psnet.ahrq.gov/issue/healthcare-simulation-nursing-practice
Simulation is an established method to examine nursing process resilience and develop non-techni…
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psnet.ahrq.gov/node/33991/psn-pdf
May 04, 2015 - Oregon Patient Safety Commission.
May 4, 2015
Oregon State Legislature. HB 2349 (2003).
https://psnet.ahrq.gov/issue/oregon-patient-safety-commission
Established the patient safety center in the state of Oregon.
https://psnet.ahrq.gov/issue/oregon-patient-safety-commission
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psnet.ahrq.gov/issue/development-leapfrog-methodology-evaluating-hospital-implemented-inpatient-computerized
May 27, 2011 - Commentary
Development of the Leapfrog methodology for evaluating hospital implemented inpatient computerized physician order entry systems.
Citation Text:
Kilbridge PM, Welebob EM, Classen DC. Development of the Leapfrog methodology for evaluating hospital implemented inpatient comput…
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psnet.ahrq.gov/node/74193/psn-pdf
December 15, 2021 - Input for the TeamSTEPPS Curriculum Updates.
December 15, 2021
Rockville MD, Agency for Healthcare Quality and Research. December 7, 2021.
https://psnet.ahrq.gov/issue/input-teamstepps-curriculum-updates
The TeamSTEPPS program is an established approach for improving teamwork and communication in
health care. This…
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psnet.ahrq.gov/node/50388/psn-pdf
September 25, 2019 - Patient Safety.
September 25, 2019
Harrisburg, PA: Patient Safety Authority. ISSN 2641-4716.
https://psnet.ahrq.gov/issue/patient-safety-17
The Pennsylvania Patient Safety Authority is a long-established source of patient safety data analysis and
application-focused commentary. Their publishing output aims to gene…
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psnet.ahrq.gov/node/39099/psn-pdf
November 11, 2009 - African Partnerships for Patient Safety.
November 11, 2009
https://psnet.ahrq.gov/issue/african-partnerships-patient-safety
This Web site establishes a forum for hospitals in Europe and Africa to support partnership development
and share learnings to drive patient safety improvements.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/36507/psn-pdf
February 17, 2009 - Centre for Patient Safety and Service Quality.
February 17, 2009
https://psnet.ahrq.gov/issue/centre-patient-safety-and-service-quality
This research program was established to explore the nature of medical harm, study its causes, and
understand how to improve the safety of health care.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/865721/psn-pdf
May 01, 2024 - Patient Safety Rights Charter.
May 1, 2024
Geneva, Switzerland: World Health Organization; April 2024. ISBN: 9789240093249.
https://psnet.ahrq.gov/issue/patient-safety-rights-charter
Patients have the right to expect safe, equitable, high-quality care. This 10-point charter serves to describe
the establishmen…
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psnet.ahrq.gov/node/35450/psn-pdf
January 01, 2006 - NHS Redress Act 2006.
November 2, 2005
United Kingdom Parliament, 2006 Chapter 44.
https://psnet.ahrq.gov/issue/nhs-redress-act-2006
This act establishes a process for the National Health Service to handle small claims from medical
mistakes without litigation.
https://psnet.ahrq.gov/issue/nhs-redress-act-20…
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psnet.ahrq.gov/node/60302/psn-pdf
May 06, 2020 - Fighting against COVID-19: innovative strategies for
clinical pharmacists.
May 6, 2020
Li H, Zheng S, Liu F, et al. Fighting against COVID-19: innovative strategies for clinical pharmacists. Res
Social Adm Pharm. 2020. doi:10.1016/j.sapharm.2020.04.003.
https://psnet.ahrq.gov/issue/fighting-against-covid-19-innova…
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psnet.ahrq.gov/node/841199/psn-pdf
December 07, 2022 - Press Play on Safety Conversations.
December 7, 2022
Healthcare Excellence Canada. 2022.
https://psnet.ahrq.gov/issue/press-play-safety-conversations
After a patient safety incident, effective discussions are critical for healing and improvement. This website
houses collections of materials to support constructive…
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psnet.ahrq.gov/node/38514/psn-pdf
September 29, 2017 - Reportable incidents.
September 29, 2017
Barishansky RM, Glick DE. Reportable incidents. Establishing policies and procedures for when calls go
wrong. EMS magazine. 2009;38(3):43-7.
https://psnet.ahrq.gov/issue/reportable-incidents
This article explains the elements of preparing policies and procedures for reporta…
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psnet.ahrq.gov/issue/visual-medication-schedule-improve-anticoagulation-control-randomized-controlled-trial
October 21, 2010 - Study
A visual medication schedule to improve anticoagulation control: a randomized, controlled trial.
Citation Text:
Machtinger EL, Wang F, Chen L-L, et al. A visual medication schedule to improve anticoagulation control: a randomized, controlled trial. Jt Comm J Qual Patient Saf. 2007;…
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psnet.ahrq.gov/issue/use-medical-emergency-teams-medical-and-surgical-patients-impact-patient-nurse-and
November 09, 2011 - Study
The use of medical emergency teams in medical and surgical patients: impact of patient, nurse and organisational characteristics.
Citation Text:
Schmid-Mazzoccoli A, Hoffman LA, Wolf GA, et al. The use of medical emergency teams in medical and surgical patients: impact of patient,…