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  1. Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges. | PSNet

    psnet.ahrq.gov/issue/responsibility-quality-improvement-and-patient-safety-hospital-board-and-medical-staff
    April 27, 2010 - Review Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges. Citation Text: Goeschel CA, Wachter R, Pronovost P. Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challeng…

  2. Advancing health equity in patient safety: a reckoning, challenge and opportunity. | PSNet

    psnet.ahrq.gov/issue/advancing-health-equity-patient-safety-reckoning-challenge-and-opportunity
    February 23, 2022 - Commentary Advancing health equity in patient safety: a reckoning, challenge and opportunity. Citation Text: Chin MH. Advancing health equity in patient safety: a reckoning, challenge and opportunity. BMJ Qual Saf. 2021;30(5):356-361. doi:10.1136/bmjqs-2020-012599. Copy Citation Fo…

  3. Relationship between preventable hospital deaths and other measures of safety: an exploratory study. | PSNet

    psnet.ahrq.gov/issue/relationship-between-preventable-hospital-deaths-and-other-measures-safety-exploratory-study
    November 12, 2014 - Study Relationship between preventable hospital deaths and other measures of safety: an exploratory study. Citation Text: Hogan H, Healey F, Neale G, et al. Relationship between preventable hospital deaths and other measures of safety: an exploratory study. Int J Qual Health Care. 2014;2…

  4. Interventions and measurements of highly reliable/resilient organization implementations: a literature review. | PSNet

    psnet.ahrq.gov/issue/interventions-and-measurements-highly-reliableresilient-organization-implementations
    July 21, 2021 - Review Interventions and measurements of highly reliable/resilient organization implementations: a literature review. Citation Text: Cantu J, Tolk J, Fritts S, et al. Interventions and measurements of highly reliable/resilient organization implementations: a literature review. Appl Ergon…

  5. The Quality in Australian Health Care Study. | PSNet

    psnet.ahrq.gov/issue/quality-australian-health-care-study
    February 02, 2022 - Study Classic The Quality in Australian Health Care Study. Citation Text: Wilson RML, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust. 2019;163(9):458-471. doi:10.5694/j.1326-5377.1995.tb124691.x. Copy Citation Forma…

  6. Identifying unintended consequences of quality indicators: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/identifying-unintended-consequences-quality-indicators-qualitative-study
    March 04, 2020 - Study Identifying unintended consequences of quality indicators: a qualitative study. Citation Text: Lester HE, Hannon KL, Campbell S. Identifying unintended consequences of quality indicators: a qualitative study. BMJ Qual Saf. 2011;20(12):1057-61. doi:10.1136/bmjqs.2010.048371. Cop…

  7. Just Culture Webcast Presentation (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-2-presentation.pdf
    May 01, 2007 - Just Culture Webcast Presentation University of North Carolina Health System 13 Celeste Mayer, PhD University of North Carolina Health Care System, Chapel Hill, NC UNC Medical Center • Public Academic Medical Center • Memorial, Children’s, Neurosciences, Women’s and Cancer Hospital • ~850 beds • Chapel Hill, N…

  8. Animated stories of medical error as a means of teaching undergraduates patient safety: an evaluation study. | PSNet

    psnet.ahrq.gov/issue/animated-stories-medical-error-means-teaching-undergraduates-patient-safety-evaluation-study
    June 10, 2020 - Study Animated stories of medical error as a means of teaching undergraduates patient safety: an evaluation study. Citation Text: Cooper K, Hatfield E, Yeomans J. Animated stories of medical error as a means of teaching undergraduates patient safety: an evaluation study. Perspect Med Edu…

  9. AHRQ Research Helps Pharmacists in Mentoring Program to Reduce Drug Errors in Emergency Departments | Agency for Healthcare Research and Quality

    www.ahrq.gov/news/newsroom/case-studies/cquips0802.html
    October 01, 2014 - AHRQ Research Helps Pharmacists in Mentoring Program to Reduce Drug Errors in Emergency Departments Search All Impact Case Studies June 2008 AHRQ-sponsored research on how clinical pharmacy services can reduce medication-related errors in hospital emergency departments has been put to use in hospitals in a …

  10. Why do doctors make mistakes? A study of the role of salient distracting clinical features. | PSNet

    psnet.ahrq.gov/issue/why-do-doctors-make-mistakes-study-role-salient-distracting-clinical-features
    July 03, 2014 - Study Why do doctors make mistakes? A study of the role of salient distracting clinical features. Citation Text: Mamede S, Van Gog T, Van den Berge K, et al. Why do doctors make mistakes? A study of the role of salient distracting clinical features. Acad Med. 2014;89(1):114-20. doi:10.10…

  11. A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety. | PSNet

    psnet.ahrq.gov/issue/qualitative-study-systemic-influences-paramedic-decision-making-care-transitions-and-patient
    January 08, 2014 - Study A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety. Citation Text: O'Hara R, Johnson M, Siriwardena N, et al. A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety. J He…

  12. The role of dynamic trade-offs in creating safety—a qualitative study of handover across care boundaries in emergency care. | PSNet

    psnet.ahrq.gov/issue/role-dynamic-trade-offs-creating-safety-qualitative-study-handover-across-care-boundaries
    January 21, 2015 - Study The role of dynamic trade-offs in creating safety—a qualitative study of handover across care boundaries in emergency care. Citation Text: Sujan M, Spurgeon P, Cooke M. The role of dynamic trade-offs in creating safety—A qualitative study of handover across care boundaries in emerg…

  13. Introduction | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/match/intro.html
    July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation Introduction Previous Page Next Page Table of Contents Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation Introduction Chapter 1. Building the Project Founda…

  14. Patient safety climate in US hospitals: variation by management level. | PSNet

    psnet.ahrq.gov/issue/patient-safety-climate-us-hospitals-variation-management-level
    November 18, 2009 - Study Classic Patient safety climate in US hospitals: variation by management level. Citation Text: Singer SJ, Falwell A, Gaba DM, et al. Patient safety climate in US hospitals: variation by management level. Med Care. 2008;46(11):1149-56. doi:10.1097/MLR.0b013e…

  15. Acknowledgments | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/acknowledgments.html
    June 01, 2018 - Chartbook on Care Coordination Acknowledgments Previous Page Next Page Table of Contents Chartbook on Care Coordination Acknowledgments Care Coordination Trends in Care Coordination Measures Transitions of Care Preventable Emergency Department Visits Potentially Avoidable Hospitalization…

  16. Hospital admissions associated with medication non-adherence: a systematic review of prospective observational studies. | PSNet

    psnet.ahrq.gov/issue/hospital-admissions-associated-medication-non-adherence-systematic-review-prospective
    August 28, 2013 - Review Emerging Classic Hospital admissions associated with medication non-adherence: a systematic review of prospective observational studies. Citation Text: Mongkhon P, Ashcroft DM, Scholfield N, et al. Hospital admissions associated with medication non-adhere…

  17. Acknowledgments | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/nhqrdr/chartbooks/careaffordability/acknowledgments.html
    June 01, 2018 - Chartbook on Care Affordability Acknowledgments Previous Page Next Page Table of Contents Chartbook on Care Affordability Acknowledgments Care Affordability Care Affordability Trends and Measures Measures of Access Problems Due to Health Care Costs Measures of Inefficiency Supplemental …

  18. A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy. | PSNet

    psnet.ahrq.gov/issue/review-healthcare-failure-mode-and-effects-analysis-hfmea-radiotherapy
    June 13, 2011 - Review A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy. Citation Text: Giardina M, Cantone MC, Tomarchio E, et al. A Review of Healthcare Failure Mode and Effects Analysis (HFMEA) in Radiotherapy. Health Phys. 2016;111(4):317-26. doi:10.1097/HP.0000000000…

  19. Personal health records: a randomized trial of effects on elder medication safety. | PSNet

    psnet.ahrq.gov/issue/personal-health-records-randomized-trial-effects-elder-medication-safety
    November 16, 2022 - Study Personal health records: a randomized trial of effects on elder medication safety. Citation Text: Chrischilles EA, Hourcade JP, Doucette W, et al. Personal health records: a randomized trial of effects on elder medication safety. J Am Med Inform Assoc. 2014;21(4):679-86. doi:10.113…

  20. Developing a conceptual framework for patient safety culture in emergency department: a review of the literature. | PSNet

    psnet.ahrq.gov/issue/developing-conceptual-framework-patient-safety-culture-emergency-department-review-literature
    March 02, 2011 - Review Developing a conceptual framework for patient safety culture in emergency department: a review of the literature. Citation Text: Alshyyab MA, FitzGerald G, Dingle K, et al. Developing a conceptual framework for patient safety culture in emergency department: A review of the litera…
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