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psnet.ahrq.gov/node/36968/psn-pdf
February 15, 2011 - The hospital discharge: a review of a high risk care
transition with highlights of a reengineered discharge
process.
February 15, 2011
Greenwald JL, Denham CR, Jack BW. The Hospital Discharge. J Patient Saf. 2008;3(2).
doi:10.1097/01.jps.0000236916.94696.12.
https://psnet.ahrq.gov/issue/hospital-discharge-review…
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psnet.ahrq.gov/node/37898/psn-pdf
July 09, 2008 - Patient safety in obstetrics: what aviators, firefighters and
others can teach us.
July 9, 2008
Guise J-M, Lowe NK, Connell L. Patient Safety in Obstetrics: What Aviators, Firefighters and Others Can
Teach Us. Nurs Womens Health. 2008;12(3):208-215. doi:10.1111/j.1751-486x.2008.00325.x.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/39576/psn-pdf
September 25, 2010 - Taking Care of Myself: A Guide for When I Leave the
Hospital.
September 25, 2010
Rockville, MD: Agency for Healthcare Research and Quality; April 2010. AHRQ Publication No. 10-0059.
https://psnet.ahrq.gov/issue/taking-care-myself-guide-when-i-leave-hospital
This guide provides patients with information they need t…
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psnet.ahrq.gov/node/36924/psn-pdf
April 21, 2011 - A cluster randomized clinical trial to improve prescribing
patterns in ambulatory pediatrics.
April 21, 2011
Davis RL, Wright J, Chalmers F, et al. A cluster randomized clinical trial to improve prescribing patterns in
ambulatory pediatrics. PLoS Clin Trials. 2007;2(5):e25.
https://psnet.ahrq.gov/issue/cluster-ran…
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psnet.ahrq.gov/node/35414/psn-pdf
May 21, 2014 - Assessment of the National Patient Safety Initiative:
Context and Baseline Evaluation Report 1.
May 21, 2014
Santa Monica, CA: RAND Corporation; 2005. ISBN 0833037870.
https://psnet.ahrq.gov/issue/assessment-national-patient-safety-initiative-context-and-baseline-evaluation-
report-1
The authors report on the his…
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psnet.ahrq.gov/node/37719/psn-pdf
July 17, 2018 - AHRQ Health Care Innovations Exchange.
July 17, 2018
Agency for Healthcare Research and Quality. 2008-2016.
https://psnet.ahrq.gov/issue/ahrq-health-care-innovations-exchange
This AHRQ resource provided a searchable collection of innovations in health care, opportunities for
medical providers and administrators to…
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psnet.ahrq.gov/node/38297/psn-pdf
May 21, 2014 - Assessment of the AHRQ Patient Safety Initiative: Focus
on Implementation and Dissemination Evaluation Report
III.
May 21, 2014
Farley DO, Damberg CL, Ridgely MS, et al. Santa Monica, CA: RAND Corporation; 2007. ISBN:
9780833042170
https://psnet.ahrq.gov/issue/assessment-ahrq-patient-safety-initiative-focus-imple…
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psnet.ahrq.gov/node/860390/psn-pdf
January 10, 2024 - Key factors for effective implementation of healthcare
workers support interventions after patient safety
incidents in health organisations: a scoping review.
January 10, 2024
Guerra-Paiva S, Lobão MJ, Simões DG, et al. Key factors for effective implementation of healthcare
workers support interventions after pati…
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psnet.ahrq.gov/node/35852/psn-pdf
April 12, 2006 - New York, NY: The Commonwealth Fund; 2006.
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psnet.ahrq.gov/node/837044/psn-pdf
May 04, 2022 - New York, NY: Commonwealth Fund: April 2022.
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psnet.ahrq.gov/node/35015/psn-pdf
June 16, 2011 - Keeping Patients Safe: Transforming the Work
Environment of Nurses.
June 16, 2011
Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care
Services. Washington, DC: The National Academies Press; 2004. ISBN: 9780309090674.
https://psnet.ahrq.gov/issue/keeping-patients-safe-trans…
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psnet.ahrq.gov/node/36637/psn-pdf
January 14, 2011 - The effect of the fit between organizational culture and
structure on medication errors in medical group
practices.
January 14, 2011
Kaissi A, Kralewski J, Dowd B, et al. The effect of the fit between organizational culture and structure on
medication errors in medical group practices. Health Care Manage Rev. 2007…
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psnet.ahrq.gov/node/40430/psn-pdf
October 18, 2011 - Eliminating CLABSI: A National Patient Safety Imperative.
October 18, 2011
Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-
0037-1-EF.
https://psnet.ahrq.gov/issue/eliminating-clabsi-national-patient-safety-imperative
This publication reports the impact hospital p…
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psnet.ahrq.gov/node/35338/psn-pdf
May 27, 2011 - The effect of automated alerts on provider ordering
behavior in an outpatient setting.
May 27, 2011
Steele AW, Eisert S, Witter J, et al. The effect of automated alerts on provider ordering behavior in an
outpatient setting. PLoS Med. 2005;2(9):e255. doi:10.1371/journal.pmed.0020255.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/37332/psn-pdf
November 14, 2007 - Is Our Pharmacy Meeting Patients' Needs? A Pharmacy
Health Literacy Assessment Tool User's Guide.
November 14, 2007
Jacobson KL, Gazmararian JA, Kripalani S, et al. Rockville, MD: Agency for Healthcare Research and
Quality. October 2007. AHRQ Publication No. 07-0051.
https://psnet.ahrq.gov/issue/our-pharmacy-meeti…
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psnet.ahrq.gov/node/40198/psn-pdf
February 09, 2011 - Measures and measurement of high-performance work
systems in health care settings: propositions for
improvement.
February 9, 2011
Etchegaray J, St John C, Thomas EJ. Measures and measurement of high-performance work systems in
health care settings: Propositions for improvement. Health Care Manage Rev. 2011;36(1):3…
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psnet.ahrq.gov/node/35304/psn-pdf
July 14, 2009 - Medication error in the care of HIV/AIDS patients:
electronic surveillance, confirmation, and adverse events.
July 14, 2009
DeLorenze GN, Follansbee SF, Nguyen DP, et al. Medication error in the care of HIV/AIDS patients:
electronic surveillance, confirmation, and adverse events. Med Care. 2005;43(9 Suppl):III63-II…
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psnet.ahrq.gov/node/38213/psn-pdf
November 12, 2008 - AHRQ announces interest in research on diagnostic
errors in ambulatory care settings.
November 12, 2008
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 25, 2007.
Publication No. NOT-HS-08-002.
https://psnet.ahrq.gov/issue/ahrq-announces-interest-research-diagnostic-error…
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psnet.ahrq.gov/node/46800/psn-pdf
May 16, 2018 - Ireland investigates cervical cancer screening scandal.
May 16, 2018
O'Loughlin E. New York Times. April 30, 2018.
https://psnet.ahrq.gov/issue/ireland-investigates-cervical-cancer-screening-scandal
Large-scale adverse events should lead to system examination and improvement. This newspaper article
reports on misr…
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psnet.ahrq.gov/node/60232/psn-pdf
April 15, 2020 - Sustaining innovations in complex health care
environments: a multiple-case study of rapid response
teams.
April 15, 2020
Stolldorf DP, Havens DS, Jones CB. Sustaining innovations in complex health care environments: a
multiple-case study of rapid response teams. J Patient Saf. 2020;16(1).
doi:10.1097/pts.0000000…