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psnet.ahrq.gov/node/48014/psn-pdf
July 10, 2019 - Patient safety morning report: innovation in teaching core
patient safety principles to third-year medical students.
July 10, 2019
Beekman M, Emani VK, Wolford R, et al. Patient Safety Morning Report: Innovation in Teaching Core
Patient Safety Principles to Third-Year Medical Students. J Med Educ Curric Dev.
2019;…
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psnet.ahrq.gov/node/72530/psn-pdf
January 01, 2021 - A realist synthesis of pharmacist-conducted medication
reviews in primary care after leaving hospital: what works
for whom and why?
December 2, 2020
Luetsch K, Rowett D, Twigg MJ. A realist synthesis of pharmacist-conducted medication reviews in primary
care after leaving hospital: what works for whom and why? BMJ…
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October 07, 2020 - National Nursing Home COVID Action Network.
October 7, 2020
Rockville, MD: Agency for Healthcare Research and Quality; September 2020.
https://psnet.ahrq.gov/issue/national-nursing-home-covid-action-network
Nursing home residents are especially vulnerable to COVID-19 due to their age, and communal living
condition…
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psnet.ahrq.gov/node/36634/psn-pdf
March 03, 2011 - Surgeon information transfer and communication: factors
affecting quality and efficiency of inpatient care.
March 3, 2011
Williams RG, Silverman R, Schwind C, et al. Surgeon information transfer and communication: factors
affecting quality and efficiency of inpatient care. Ann Surg. 2007;245(2):159-69.
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September 28, 2016 - PIPc study: development of indicators of potentially
inappropriate prescribing in children (PIPc) in primary
care using a modified Delphi technique.
September 28, 2016
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prescribing in children (PIPc) in primary…
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February 17, 2017 - Disclosing adverse events to patients: international
norms and trends.
February 17, 2017
Wu AW, McCay L, Levinson W, et al. Disclosing Adverse Events to Patients: International Norms and
Trends. J Patient Saf. 2017;13(1):43-49. doi:10.1097/PTS.0000000000000107.
https://psnet.ahrq.gov/issue/disclosing-adverse-event…
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psnet.ahrq.gov/node/46031/psn-pdf
April 12, 2017 - Chief of Residents for Quality Improvement and Patient
Safety: a recipe for a new role in graduate medical
education.
April 12, 2017
Ferraro K, Zernzach R, Maturo S, et al. Chief of Residents for Quality Improvement and Patient Safety: A
Recipe for a New Role in Graduate Medical Education. Mil Med. 2017;182(3):e17…
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June 16, 2011 - The effect of executive walk rounds on nurse safety
climate attitudes: a randomized trial of clinical units.
June 16, 2011
Thomas EJ, Sexton B, Neilands TB, et al. The effect of executive walk rounds on nurse safety climate
attitudes: a randomized trial of clinical units[ISRCTN85147255] [corrected]. BMC Health Serv…
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January 01, 2025 - Hospital commitments to address diagnostic errors: an
assessment of 95 US hospitals.
September 4, 2024
Campione Russo A, Tilly J?L, Kaufman L, et al. Hospital commitments to address diagnostic errors: an
assessment of 95 US hospitals. J Hosp Med. 2025;20(2):120-134. doi:10.1002/jhm.13485.
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July 05, 2017 - Root-cause analysis: swatting at mosquitoes versus
draining the swamp.
July 5, 2017
Trbovich PL, Shojania KG. Root-cause analysis: swatting at mosquitoes versus draining the swamp. BMJ
Qual Saf. 2017;26(5):350-353. doi:10.1136/bmjqs-2016-006229.
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psnet.ahrq.gov/node/38485/psn-pdf
June 23, 2017 - Impact of a comprehensive patient safety strategy on
obstetric adverse events.
June 23, 2017
Pettker CM, Thung SF, Norwitz ER, et al. Impact of a comprehensive patient safety strategy on obstetric
adverse events. Am J Obstet Gynecol. 2009;200(5):492.e1-8. doi:10.1016/j.ajog.2009.01.022.
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psnet.ahrq.gov/node/867631/psn-pdf
February 26, 2025 - Implicit bias in the patient descriptor "homeless" and its
association with emergency department opioid
administration and disposition.
February 26, 2025
Lauricella M, Nene RV, Coyne CJ, et al. Implicit bias in the patient descriptor “homeless” and its
association with emergency department opioid administration an…
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psnet.ahrq.gov/node/49838/psn-pdf
August 01, 2018 - An Untimely End Despite End-of-Life Care Planning
August 1, 2018
Elia G, Barbour S, Anderson WG. An Untimely End Despite End-of-Life Care Planning. PSNet [internet].
2018.
https://psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
The Case
A 76-year-old man was admitted to the intensive care unit (…
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psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - SPOTLIGHT CASE
Discharged with IV antibiotics: When issues arise, who manages the complications?
Citation Text:
Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the complications?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
February 21, 2024 - The Safety Challenges of Supervision and Night Coverage in Academic Residency
Citation Text:
Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019…
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psnet.ahrq.gov/node/863650/psn-pdf
February 28, 2024 - respiratory therapists, physical therapists, social workers, case management staff,
and pharmacy staff)
Establishing
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psnet.ahrq.gov/node/836841/psn-pdf
June 01, 2020 - facility efforts should focus on
Ensuring necessary staffing to schedule and complete home visits,
Establishing
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psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
July 23, 2024 - Canada attended. a To-date, approximately 30 organizations have engaged Penn Medicine with interest in establishing
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psnet.ahrq.gov/node/60363/psn-pdf
March 01, 2021 - Transition Coaches® Reduce Readmissions for Medicare
Patients With Complex Postdischarge Needs
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-
postdischarge-needs
Summary
Under a program kn…
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psnet.ahrq.gov/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance
Lance L. Roberts, MS; Marcia M. Ward, PhD; Thomas C. Evans, MD | April 1, 2010
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