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2941. Patient safety: listen to whistleblowers. | PSNet
      psnet.ahrq.gov/issue/patient-safety-listen-whistleblowers
      May 22, 2019 - May 22, 2019 Evaluation of clinical practice guidelines on fall prevention and management

2942. Learning and sharing safety lessons to improve patient care. | PSNet
      psnet.ahrq.gov/issue/learning-and-sharing-safety-lessons-improve-patient-care
      August 07, 2019 - August 14, 2019 Root cause analysis of reported patient falls in ORs in the Veterans

2943. From the school of nursing quality and safety officer: nursing students' use of safety reporting tools and their perception of safety issues in clinical settings. | PSNet
      psnet.ahrq.gov/issue/school-nursing-quality-and-safety-officer-nursing-students-use-safety-reporting-tools-and
      October 19, 2022 - April 6, 2012 ROI for a fall prevention intervention: invest a little, save a lot.

2944. Improving care transitions: current practice and future opportunities for pharmacists. | PSNet
      psnet.ahrq.gov/issue/improving-care-transitions-current-practice-and-future-opportunities-pharmacists
      December 12, 2012 - Commentary Improving care transitions: current practice and future opportunities for pharmacists. Citation Text: Pharmacy AC of C, Hume AL, Kirwin J, et al. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012;32(11):e326-37. doi…

2945. Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit. | PSNet
      psnet.ahrq.gov/issue/handoff-checklists-improve-reliability-patient-handoffs-operating-room-and-postanesthesia
      December 29, 2014 - August 25, 2021 Evaluation of clinical practice guidelines on fall prevention and management

2946. Nurses: Guilty verdict for dosing mistake could cost lives. | PSNet
      psnet.ahrq.gov/issue/nurses-guilty-verdict-dosing-mistake-could-cost-lives
      April 27, 2022 - Newspaper/Magazine Article Nurses: Guilty verdict for dosing mistake could cost lives. Citation Text: Nurses: Guilty verdict for dosing mistake could cost lives. Loller T. Associated Press. March 30, 2022. Copy Citation Save Save to your library …

2947. Tackling implicit bias in health care. | PSNet
      psnet.ahrq.gov/issue/tackling-implicit-bias-health-care
      December 01, 2021 - Commentary Tackling implicit bias in health care. Citation Text: Sabin JA. Tackling implicit bias in health care. N Engl J Med. 2022;387(2):105-107. doi:10.1056/nejmp2201180. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…

2948. Education is “predictably disappointing” and should never be relied upon alone to improve safety. | PSNet
      psnet.ahrq.gov/issue/education-predictably-disappointing-and-should-never-be-relied-upon-alone-improve-safety
      June 15, 2022 - Newspaper/Magazine Article Education is “predictably disappointing” and should never be relied upon alone to improve safety. Citation Text: Education is “predictably disappointing” and should never be relied upon alone to improve safety. ISMP Medication Safety Alert! Acute care edition. …

2949. EAU policy on live surgery events. | PSNet
      psnet.ahrq.gov/issue/eau-policy-live-surgery-events
      December 29, 2014 - March 24, 2010 Evaluation of clinical practice guidelines on fall prevention and management

2950. A crisis within a crisis. | PSNet
      psnet.ahrq.gov/issue/crisis-within-crisis
      May 05, 2021 - Newspaper/Magazine Article A crisis within a crisis. Citation Text: A crisis within a crisis. Ellis NT, Broaddus A. CNN. August 25, 2021.  Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter …

2951. Airway carts: a systems-based approach to airway safety. | PSNet
      psnet.ahrq.gov/issue/airway-carts-systems-based-approach-airway-safety
      July 21, 2010 - Study Airway carts: a systems-based approach to airway safety. Citation Text: Kane BG, Bond WF, Worrilow CC, et al. Airway Carts. J Patient Saf. 2008;2(3). doi:10.1097/01.jps.0000242995.09037.07. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…

2952. Findings and Lessons From the Improving Management of Individuals With Complex Health Care Needs Through Health IT Grant Initiative. | PSNet
      psnet.ahrq.gov/issue/findings-and-lessons-improving-management-individuals-complex-health-care-needs-through
      October 02, 2013 - February 27, 2013 Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care

2953. Re-Engineered Discharge (RED) Toolkit. | PSNet
      psnet.ahrq.gov/issue/re-engineered-discharge-red-toolkit
      June 20, 2014 - August 17, 2016 Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care

2954. Harborview Medical Center Uses AHRQ’s Quality Indicators To Improve Patient Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsroom/case-studies/202504.html
      June 01, 2025 - The latter two areas are primarily concerned with PSIs for pressure ulcers and falls.

2955. The quality of pharmacologic care for vulnerable older patients. | PSNet
      psnet.ahrq.gov/issue/quality-pharmacologic-care-vulnerable-older-patients
      August 27, 2012 - Study The quality of pharmacologic care for vulnerable older patients. Citation Text: Higashi T, Shekelle PG, Solomon DH, et al. The quality of pharmacologic care for vulnerable older patients. Ann Intern Med. 2004;140(9):714-20. Copy Citation Format: Google Scholar PubMe…

2956. Opioids for pain management in older adults: strategies for safe prescribing. | PSNet
      psnet.ahrq.gov/issue/opioids-pain-management-older-adults-strategies-safe-prescribing
      January 26, 2022 - Commentary Opioids for pain management in older adults: strategies for safe prescribing. Citation Text: Davies PS. Opioids for pain management in older adults. Nurse Pract. 2017;42(2). doi:10.1097/01.npr.0000511772.62176.10. Copy Citation Format: DOI Google Scholar BibTeX E…

2957. Skin-deep diagnosis: affective bias and zebra retreat complicating the diagnosis of systemic sclerosis. | PSNet
      psnet.ahrq.gov/issue/skin-deep-diagnosis-affective-bias-and-zebra-retreat-complicating-diagnosis-systemic
      July 29, 2020 - Commentary Skin-deep diagnosis: affective bias and zebra retreat complicating the diagnosis of systemic sclerosis. Citation Text: Miller CS. Skin-deep diagnosis: affective bias and zebra retreat complicating the diagnosis of systemic sclerosis. Am J Med Sci. 2013;345(1):53-6. doi:10.1…

2958. Reducing harm to patients. Using patient safety dashboards at the board level. | PSNet
      psnet.ahrq.gov/issue/reducing-harm-patients-using-patient-safety-dashboards-board-level
      February 22, 2010 - March 21, 2012 Perspective Implementing a Fall Prevention

2959. Recognizing the importance of whistleblowers in healthcare. | PSNet
      psnet.ahrq.gov/issue/recognizing-importance-whistleblowers-healthcare
      June 24, 2009 - Commentary Recognizing the importance of whistleblowers in healthcare. Citation Text: O'Neill N. Recognizing the importance of whistleblowers in healthcare. Nursing (Brux). 2021;51(4):54-56. doi:10.1097/01.nurse.0000736912.14380.65. Copy Citation Format: DOI Google Scholar …

2960. ASPEN parenteral nutrition safety consensus recommendations: translation into practice. | PSNet
      psnet.ahrq.gov/issue/aspen-parenteral-nutrition-safety-consensus-recommendations-translation-practice
      February 17, 2015 - Commentary ASPEN parenteral nutrition safety consensus recommendations: translation into practice. Citation Text: Ayers P, Adams S, Boullata JI, et al. A.S.P.E.N. parenteral nutrition safety consensus recommendations: translation into practice. Nutr Clin Pract. 2014;29(3):277-82. doi:10.…