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psnet.ahrq.gov/classics
August 01, 2023 - Healthcare Research and Quality
Safety culture has been described as a key to establishing
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psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
July 08, 2022 - way to mitigate this risk is by standardizing opioid prescribing patterns, leveraging technology and establishing
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psnet.ahrq.gov/node/33594/psn-pdf
November 18, 2021 - Establishing psychological safety for participants is
essential, regardless of the type of debriefing
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psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - November 2, 2011
Perspective
Establishing a Safety Culture
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psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
January 22, 2020 - Describe the role of leaders in establishing and maintaining a culture of safety.
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psnet.ahrq.gov/issue/what-us-hospitals-are-currently-doing-prevent-common-device-associated-infections-results
June 21, 2023 - Study
What US hospitals are currently doing to prevent common device-associated infections: results from a national survey.
Citation Text:
Saint S, Greene MT, Fowler KE, et al. What US hospitals are currently doing to prevent common device-associated infections: results from a national s…
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psnet.ahrq.gov/issue/safe-practice-recommendations-use-copy-forward-nursing-flow-sheets-hospital-settings
May 18, 2022 - Study
Safe practice recommendations for the use of copy-forward with nursing flow sheets in hospital settings.
Citation Text:
Patterson ES, Sillars DM, Staggers N, et al. Safe Practice Recommendations for the Use of Copy-Forward with Nursing Flow Sheets in Hospital Settings. Jt Comm J Qu…
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psnet.ahrq.gov/issue/development-evidence-based-framework-factors-contributing-patient-safety-incidents-hospital
June 25, 2014 - Review
Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review.
Citation Text:
Lawton R, McEachan RRC, Giles SJ, et al. Development of an evidence-based framework of factors contributing to patient safety …
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psnet.ahrq.gov/issue/are-teaching-hospitals-treated-fairly-hospital-acquired-condition-reduction-program
July 11, 2018 - Study
Are teaching hospitals treated fairly in the Hospital-Acquired Condition Reduction Program?
Citation Text:
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.000…
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psnet.ahrq.gov/issue/communication-between-primary-and-secondary-care-deficits-and-danger
September 23, 2020 - Study
Communication between primary and secondary care: deficits and danger.
Citation Text:
Dinsdale E, Hannigan A, O’Connor R, et al. Communication between primary and secondary care: deficits and danger. Fam Pract. 2019;17(1):63-68. doi:10.1093/fampra/cmz037.
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psnet.ahrq.gov/issue/health-economic-evaluation-infection-prevention-and-control-program-are-quality-and-patient
June 02, 2021 - Study
Health economic evaluation of an infection prevention and control program: are quality and patient safety programs worth the investment?
Citation Text:
Raschka S, Dempster L, Bryce E. Health economic evaluation of an infection prevention and control program: are quality and patien…
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psnet.ahrq.gov/web-mm/walking-patient-missing-drain
April 01, 2006 - Walking Patient, Missing Drain
Citation Text:
Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar BibTeX EndNote …
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psnet.ahrq.gov/node/33695/psn-pdf
April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest
for Transparency in U.S. Hospitals' Patient Safety
Performance
April 1, 2010
Roberts LL, Ward MM, Evans TC. The Role of the National Quality Forum (NQF) in the Quest for
Transparency in U.S. Hospitals' Patient Safety Performance. PSNet [internet]. 2010.
ht…
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psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx
Spotlight
Premature Closure: Was it Just Syncope?
Source and Credits
• This presentation is based on the November 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit i…
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psnet.ahrq.gov/node/33661/psn-pdf
December 01, 2007 - Care Transitions
December 1, 2007
Kripalani S. Care Transitions. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/care-transitions
Perspective
Hospital discharge is often viewed as the end of an acute medical event. Goodbyes are said as patients
pack their belongings and return home. Physicians scratch …
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psnet.ahrq.gov/node/33625/psn-pdf
January 01, 2006 - Aviation Safety Methods: Quickly Adopted but Questions
Remain
January 1, 2006
Thomas EJ. Aviation Safety Methods: Quickly Adopted but Questions Remain. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain
Perspective
On August 2, 2005, Air France flig…
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psnet.ahrq.gov/node/33651/psn-pdf
June 01, 2007 - In Conversation with...Diane Rydrych, MA
June 1, 2007
In Conversation with..Diane Rydrych, MA. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
Editor's Note: Diane Rydrych, MA, is Assistant Director of the Division of Health Policy at the Minnesota
Department of Health,…
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psnet.ahrq.gov/web-mm/over-not-so-easy
April 01, 2005 - Over Not So Easy
Citation Text:
Cucina R. Over Not So Easy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/50842/psn-pdf
January 29, 2020 - Patient Identification Errors: A Systems Challenge
January 29, 2020
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
The Cases
The following four events involving five patients all involved…
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psnet.ahrq.gov/node/73515/psn-pdf
August 01, 2022 - Missouri Quality Initiative (MOQI) Reduces
Hospitalizations Among Nursing Home Residents
July 28, 2021
https://psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing-
home-residents
Summary
The MOQI seeks to reduce avoidable hospitalization among nursing home residents b…