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psnet.ahrq.gov/node/42855/psn-pdf
February 06, 2014 - Responding to clinicians who fail to follow patient safety
practices: perceptions of physicians, nurses, trainees,
and patients.
February 6, 2014
Driver TH, Katz PP, Trupin L, et al. Responding to clinicians who fail to follow patient safety practices:
perceptions of physicians, nurses, trainees, and patients. J H…
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psnet.ahrq.gov/node/43687/psn-pdf
November 12, 2014 - Changes in medical errors after implementation of a
handoff program.
November 12, 2014
Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff
program. New Engl J Med. 2014;371(19):1803-1812. doi:10.1056/NEJMsa1405556.
https://psnet.ahrq.gov/issue/changes-medical-er…
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psnet.ahrq.gov/node/49864/psn-pdf
June 01, 2019 - Describe the role of leaders in establishing and maintaining a culture of safety.
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psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
January 01, 2020 - evidenced by his inability to
advocate for himself
— The palliative care team advocated for the patient by establishing
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psnet.ahrq.gov/web-mm/production-pressures
November 16, 2022 - This factor is comprised of two elements: (i) predicting and planning workload and (ii) establishing
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psnet.ahrq.gov/node/73642/psn-pdf
August 25, 2021 - to address these
barriers, such as requiring multidisciplinary education for junior team members, establishing
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psnet.ahrq.gov/web-mm/techno-trip
May 01, 2005 - Executive order: Incentives for the use of health information technology and establishing the position
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - confronted about his behavior and apologized to the nurse, but was also told that the nursing staff would be establishing
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psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
November 10, 2025 - The authors call for establishing more relevant outcomes to evaluate interdisciplinary team interventions
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psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety
November 10, 2015 - reporting systems, promoting automated surveillance of clinical data, undertaking root cause analyses, and establishing
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psnet.ahrq.gov/web-mm/spinal-epidural-abscess
November 13, 2019 - Detailed history taking to identify potential risk factors for SEA is important in establishing the early
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psnet.ahrq.gov/primer/failure-rescue
September 15, 2024 - improve FTR rates within healthcare organizations: Recognize Staffing levels and education, including establishing
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psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
December 15, 2024 - four-step model of implementation involves identifying current practices within a health system, establishing
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psnet.ahrq.gov/web-mm/communication-error-closed-icu
July 01, 2016 - Establishing central venous access in this patient was challenging.
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psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
January 01, 2022 - way to mitigate this risk is by standardizing opioid
prescribing patterns, leveraging technology and establishing
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psnet.ahrq.gov/node/865610/psn-pdf
April 24, 2024 - Suicide Prevention in an Emergency Department
Population: ED-SAFE
April 24, 2024
https://psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
Summary
Suicide is the 12th leading cause of death in the United States, and the 3rd leading cause of death for
people ages 15-24.1 More tha…
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psnet.ahrq.gov/node/47831/psn-pdf
May 08, 2019 - What US hospitals are currently doing to prevent common
device-associated infections: results from a national
survey.
May 8, 2019
Saint S, Greene MT, Fowler KE, et al. What US hospitals are currently doing to prevent common device-
associated infections: results from a national survey. BMJ Qual Saf. 2019;28(9):741…
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psnet.ahrq.gov/node/47307/psn-pdf
December 12, 2018 - Are teaching hospitals treated fairly in the Hospital-
Acquired Condition Reduction Program?
December 12, 2018
Mohajer MA, Joiner KA, Nix DE. Are Teaching Hospitals Treated Fairly in the Hospital-Acquired Condition
Reduction Program? Acad Med. 2018;93(12):1827-1832. doi:10.1097/ACM.0000000000002399.
https://psnet.…
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psnet.ahrq.gov/node/46178/psn-pdf
December 22, 2017 - Evaluating serial strategies for preventing wrong-patient
orders in the NICU.
December 22, 2017
Adelman JS, Aschner JL, Schechter CB, et al. Evaluating Serial Strategies for Preventing Wrong-Patient
Orders in the NICU. Pediatrics. 2017;139(5). doi:10.1542/peds.2016-2863.
https://psnet.ahrq.gov/issue/evaluating-ser…
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psnet.ahrq.gov/node/45615/psn-pdf
October 26, 2016 - Mandatory provider review and pain clinic laws reduce
the amounts of opioids prescribed and overdose death
rates.
October 26, 2016
Dowell D, Zhang K, Noonan RK, et al. Mandatory Provider Review And Pain Clinic Laws Reduce The
Amounts Of Opioids Prescribed And Overdose Death Rates. Health Aff (Millwood). 2016;35(10…