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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. 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. Copy Citation Format: Googl…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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 …
  8. Psn-Pdf (pdf file)

    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 …
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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 …
  16. Psn-Pdf (pdf file)

    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 …
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. 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…
  20. Psn-Pdf (pdf file)

    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…

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