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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/40163/psn-pdf
December 21, 2014 - Integration of a formalized handoff system into the
surgical curriculum: resident perspectives and early
results.
December 21, 2014
Telem DA. Integration of a Formalized Handoff System Into the Surgical Curriculum. Archives of Surgery.
2011;146(1). doi:10.1001/archsurg.2010.294.
https://psnet.ahrq.gov/issue/integ…
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psnet.ahrq.gov/node/41056/psn-pdf
January 11, 2012 - Beyond communication: the role of standardized
protocols in a changing health care environment.
January 11, 2012
Vardaman JM, Cornell P, Gondo MB, et al. Beyond communication: the role of standardized protocols in a
changing health care environment. Health Care Manage Rev. 2012;37(1):88-97.
doi:10.1097/HMR.0b013e…
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psnet.ahrq.gov/node/73926/psn-pdf
October 06, 2021 - Good for You, Good for Us, Good for Everybody.
October 6, 2021
Ridge K. London, England: Crown Copyright; 2021. September 22, 2021.
https://psnet.ahrq.gov/issue/good-you-good-us-good-everybody
Overprescribing has attained prominence as a safety issue due to the current opioid epidemic, but it has
long reduced medi…
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psnet.ahrq.gov/node/50643/psn-pdf
November 06, 2019 - Same Day Surgery in the US; Findings of Two Inaugural
Leapfrog Surveys 2019.
November 6, 2019
Washington DC: Leapfrog Group; 2019.
https://psnet.ahrq.gov/issue/same-day-surgery-us-findings-two-inaugural-leapfrog-surveys-2019
Ambulatory surgery centers (ASC) are established venues for surgical care despite lack of …
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psnet.ahrq.gov/node/867698/psn-pdf
October 01, 2024 - Toolkit for MRSA Prevention in ICU & Non-ICU Settings.
October 1, 2024
Agency for Healthcare Research and Quality. Toolkit for MRSA Prevention in ICU & Non-ICU Settings.
October 2024.
https://psnet.ahrq.gov/issue/toolkit-mrsa-prevention-icu-non-icu-settings
Methicillin-resistant Staphylococcus aureus (MRSA) infect…
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psnet.ahrq.gov/node/39023/psn-pdf
November 19, 2018 - Pediatric Readiness in the Emergency Department.
November 19, 2018
Remick K, Gausche-Hill M, Joseph MM, et al. Pediatric Readiness in the Emergency Department.
Pediatrics. 2018;142(5):e20182459. doi:10.1542/peds.2018-2459.
https://psnet.ahrq.gov/issue/pediatric-readiness-emergency-department
This revised set of gu…
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psnet.ahrq.gov/node/851662/psn-pdf
July 26, 2023 - Mitigating bias in AI at the point of care.
July 26, 2023
Decamp M, Lindvall C. Science. 2023;381(6654):150-152.
https://psnet.ahrq.gov/issue/mitigating-bias-ai-point-care
Computerized clinical support is vulnerable to bias due to widespread health care inequalities that feed into
the systems. This article di…
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psnet.ahrq.gov/node/852458/psn-pdf
June 01, 2019 - The patient's role in patient safety.
June 1, 2019
Corina I, Abram M, Halperin D. The patient's role in patient safety. Obstet Gynecol Clin North Am.
2019;46(2):215-225. doi:10.1016/j.ogc.2019.01.004.
https://psnet.ahrq.gov/issue/patients-role-patient-safety
Patients and their families can play an important role i…
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psnet.ahrq.gov/node/838027/psn-pdf
September 07, 2022 - Advancing Anticoagulation Stewardship: A Playbook.
September 7, 2022
Washington DC; National Quality Forum and Anticoagulation Forum; 2022.
https://psnet.ahrq.gov/issue/advancing-anticoagulation-stewardship-playbook
Warfarin and other anticoagulants are high-alert medications that, if errors occur in their use, can…
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psnet.ahrq.gov/node/37412/psn-pdf
December 12, 2007 - The checklist.
December 12, 2007
Gawande A. New Yorker. December 10, 2007:86-95.
https://psnet.ahrq.gov/issue/checklist
This article by bestselling author and surgeon Atul Gawande illustrates the complexity of intensive care and
profiles Peter Pronovost, the Johns Hopkins intensivist and safety leader whose effort…
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psnet.ahrq.gov/node/838221/psn-pdf
September 28, 2022 - In Conversation With... Freya Spielberg, MD, MPH
September 28, 2022
In Conversation With.. Freya Spielberg, MD, MPH. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
Editor’s Note: Freya Spielberg, MD, MPH, is the Founder and CEO of Urgent Wellness LLC, a social
enterp…
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psnet.ahrq.gov/print/pdf/node/845971
January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Value and Patient Safety
Curated Library
Foundations
Safety is the preservation of value.
Vandeskog B. J Safety Res. 2024;89:105-115.
Safety is at the heart of safety science, and yet “safety” lacks a consensus definition among safety
resea…
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psnet.ahrq.gov/node/50825/psn-pdf
January 22, 2020 - Investigation into Detection of Retained Vaginal Swabs
and Tampons Following Childbirth.
January 22, 2020
Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.
https://psnet.ahrq.gov/issue/investigation-detection-retained-vaginal-swabs-and-tampons-following-
childbirth
Maternal care during a…
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psnet.ahrq.gov/node/38225/psn-pdf
February 16, 2011 - Changing conversations: teaching safety and quality in
residency training.
February 16, 2011
Voss JD, May NB, Schorling JB, et al. Changing conversations: teaching safety and quality in residency
training. Acad Med. 2008;83(11):1080-7. doi:10.1097/ACM.0b013e31818927f8.
https://psnet.ahrq.gov/issue/changing-convers…
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psnet.ahrq.gov/node/46767/psn-pdf
January 17, 2018 - What this computer needs is a physician: humanism and
artificial intelligence.
January 17, 2018
Verghese A, Shah NH, Harrington RA. What This Computer Needs Is a Physician: Humanism and Artificial
Intelligence. JAMA. 2018;319(1):19-20. doi:10.1001/jama.2017.19198.
https://psnet.ahrq.gov/issue/what-computer-needs-p…
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psnet.ahrq.gov/node/867347/psn-pdf
December 11, 2024 - Recommendations to ensure safety of AI in real-world
clinical care.
December 11, 2024
Sittig DF, Singh H. Recommendations to ensure safety of AI in real-world clinical care. JAMA.
2025;333(6):457-458. doi:10.1001/jama.2024.24598.
https://psnet.ahrq.gov/issue/recommendations-ensure-safety-ai-real-world-clinical-car…
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psnet.ahrq.gov/node/47739/psn-pdf
February 20, 2019 - Artificial intelligence, bias and clinical safety.
February 20, 2019
Challen R, Denny J, Pitt M, et al. Artificial intelligence, bias and clinical safety. BMJ Qual Saf.
2019;28(3):231-237. doi:10.1136/bmjqs-2018-008370.
https://psnet.ahrq.gov/issue/artificial-intelligence-bias-and-clinical-safety
Artificial intell…
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psnet.ahrq.gov/node/43569/psn-pdf
April 25, 2016 - The safe day call: reducing silos in health care through
frontline risk assessment.
April 25, 2016
Paterson C, Miller K, Benden M, et al. The Safe Day Call: Reducing Silos in Health Care Through Frontline
Risk Assessment. Jt Comm J Qual Patient Saf. 2014;40(10):476-481.
https://psnet.ahrq.gov/issue/safe-day-call-r…
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psnet.ahrq.gov/node/33962/psn-pdf
June 22, 2007 - Enacting the Washington state patient safety act requiring
hospital staffing plans for nursing services and
establishing recordkeeping and reporting requirements.
June 22, 2007
HB 1602. Washington State Legislature. 2003-2004.
https://psnet.ahrq.gov/issue/enacting-washington-state-patient-safety-act-requiring-hosp…