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psnet.ahrq.gov/node/37341/psn-pdf
January 20, 2010 - Patient-Centered Care: What Does It Take?
January 20, 2010
Shaller D. The Commonwealth Fund. October 2007.
https://psnet.ahrq.gov/issue/patient-centered-care-what-does-it-take
By sharing the insights of health care leaders, this report identifies important factors for integrating patient-
centered care into organi…
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psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - The Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis
Introduction
Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
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psnet.ahrq.gov/node/846935/psn-pdf
March 29, 2023 - Maternal Safety and Perinatal Mental Health
March 29, 2023
Allen C, Van CM, Mossburg S. Maternal Safety and Perinatal Mental Health . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
Maternal patient safety is a critical aspect of healthcare given the complex pr…
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psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
February 23, 2011 - Patient Identification Errors: A Systems Challenge
Citation Text:
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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Format:
Googl…
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psnet.ahrq.gov/node/49804/psn-pdf
September 01, 2017 - Transfusion Thresholds in Gastrointestinal Bleeding
September 1, 2017
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
Case Objectives
Describe risk factors for poor outcome in patients w…
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psnet.ahrq.gov/node/35346/psn-pdf
September 21, 2005 - Guide to Healthcare Quality: How to Know It When You
See It.
September 21, 2005
Rockville, MD: Agency for Healthcare Research and Quality; 2005.
https://psnet.ahrq.gov/issue/guide-healthcare-quality-how-know-it-when-you-see-it
Part of the Agency for Healthcare Research and Quality's (AHRQ) consumer education campa…
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psnet.ahrq.gov/node/41441/psn-pdf
July 08, 2021 - National Diabetes Inpatient Audit -- Harms.
July 8, 2021
Leeds, UK: Health and Social Care Information Centre.
https://psnet.ahrq.gov/issue/national-diabetes-inpatient-audit-2017
This annual report identified a significant number of medication errors associated with diabetes care in
acute hospitals in England and …
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psnet.ahrq.gov/node/42411/psn-pdf
July 24, 2013 - Surgical checklists: the human factor.
July 24, 2013
O'Connor P, Reddin C, O'Sullivan M, et al. Surgical checklists: the human factor. Patient Saf Surg.
2013;7(1):14. doi:10.1186/1754-9493-7-14.
https://psnet.ahrq.gov/issue/surgical-checklists-human-factor
This qualitative study identified several barriers to the …
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psnet.ahrq.gov/node/41939/psn-pdf
February 11, 2014 - The role of the electronic health record in patient safety
events.
February 11, 2014
Sparnon E, Marella WM. Pa Patient Saf Advis 2012 Dec;9(4):113-21.
https://psnet.ahrq.gov/issue/role-electronic-health-record-patient-safety-events
This piece analyzes data submitted to the Pennsylvania Patient Safety Reporting Sys…
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psnet.ahrq.gov/node/41505/psn-pdf
May 07, 2014 - Health IT Hazard Manager.
May 7, 2014
Rockville, MD: Agency for Healthcare Research and Quality. AHRQ Publication No. 12-0058-EF May 2012.
https://psnet.ahrq.gov/issue/health-it-hazard-manager
This Web site provides information associated with a software tool to identify and prevent hazards from
health information…
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psnet.ahrq.gov/node/38793/psn-pdf
August 12, 2016 - Pediatric Quality Indicators Overview.
August 12, 2016
Agency for Healthcare Research and Quality
https://psnet.ahrq.gov/issue/pediatric-quality-indicators-overview
The Agency for Healthcare Research and Quality's (AHRQ) Quality Indicators (QIs) represent quality
measures that make use of a hospital's available ad…
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psnet.ahrq.gov/node/36287/psn-pdf
September 20, 2006 - Nursing Home Complaint Investigations.
September 20, 2006
Levinson DR. Washington DC: Office of the Inspector General; July 2006. OEI-01-04-00340.
https://psnet.ahrq.gov/issue/nursing-home-complaint-investigations
This report shares findings from an assessment of Centers for Medicaid and Medicare Services response…
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psnet.ahrq.gov/node/40915/psn-pdf
January 04, 2012 - Simulation in obstetric anesthesia.
January 4, 2012
Pratt SD. Focused review: simulation in obstetric anesthesia. Anesth Analg. 2012;114(1):186-90.
doi:10.1213/ANE.0b013e3182377bbc.
https://psnet.ahrq.gov/issue/simulation-obstetric-anesthesia
This review examines how simulation training can improve performance, id…
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psnet.ahrq.gov/node/35004/psn-pdf
May 18, 2005 - Lean Six Sigma reduces medication errors.
May 18, 2005
Esimai G. Quality Progress; 2005;38(4):51-57.
https://psnet.ahrq.gov/issue/lean-six-sigma-reduces-medication-errors
The authors analyze one hospital’s quality management program. Using a Six Sigma methodology,
the program identified policy and practice changes…
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psnet.ahrq.gov/node/40437/psn-pdf
May 18, 2011 - Health Policy Brief: Improving Quality and Safety.
May 18, 2011
Bethesda, MD: Health Affairs. April 15, 2011:1-7.
https://psnet.ahrq.gov/issue/health-policy-brief-improving-quality-and-safety
This publication explores health care quality and identifies the primary challenges affecting US quality and
safety …
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psnet.ahrq.gov/node/42845/psn-pdf
December 18, 2014 - Breakdowns in the medication reconciliation process.
December 18, 2014
Gao T, Gaunt MJ. PA-PSRS Patient Saf Advis. December 2013;10:125-136.
https://psnet.ahrq.gov/issue/breakdowns-medication-reconciliation-process
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies
…
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psnet.ahrq.gov/node/35953/psn-pdf
May 24, 2006 - Too exhausted to act safely?
May 24, 2006
Spath P. Hosp Peer Rev. 2006;31(4):56-59.
https://psnet.ahrq.gov/issue/too-exhausted-act-safely
The author discusses how to identify and evaluate worker fatigue. Part II of this article outlines specific
techniques for reducing health care worker fatigue.
https://psnet.ah…
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psnet.ahrq.gov/node/33913/psn-pdf
December 22, 2014 - HCUPnet.
December 22, 2014
Agency for Healthcare Research and Quality
https://psnet.ahrq.gov/issue/hcupnet
This interactive tool identifies, tracks, analyzes, and compares statistics on hospital care. It is part of the
Healthcare Cost and Utilization Project (HCUP). With HCUPnet, users gain easy access to all nati…
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psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
June 01, 2007 - Advancing Patient Safety Through State Reporting Systems
Jill Rosenthal, MPH | June 1, 2007
View more articles from the same authors.
Citation Text:
Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. Rockville (MD): Agency for…
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psnet.ahrq.gov/node/49636/psn-pdf
October 01, 2011 - Mobility Lost in the ICU
October 1, 2011
Smith J. Mobility Lost in the ICU. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/mobility-lost-icu
Case Objectives
Describe the role of the physical therapist in the hospital and ICU.
Compare the risks from immobility with the benefits gained from a program of ther…