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psnet.ahrq.gov/node/43505/psn-pdf
April 25, 2016 - Hospitals often ignore policies on using qualified medical
interpreters.
April 25, 2016
Rice S. Language liabilities. To avoid errors, hospitals urged to use qualified interpreters for patients with
limited English. Modern healthcare. 2014;44(35):16-8, 20.
https://psnet.ahrq.gov/issue/hospitals-often-ignore-polici…
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psnet.ahrq.gov/node/44588/psn-pdf
November 21, 2016 - Patient and family advisory councils. The Massachusetts
experience.
November 21, 2016
Wachenheim D. Patient Saf Qual Healthc. December 8, 2015.
https://psnet.ahrq.gov/issue/patient-and-family-advisory-councils-massachusetts-experience
Patient and family advisory councils are considered valuable method to help hosp…
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psnet.ahrq.gov/node/46208/psn-pdf
July 12, 2017 - Improving patient safety by practicing in a just culture.
July 12, 2017
Duffy W. Improving Patient Safety by Practicing in a Just Culture. AORN J. 2017;106(1):66-68.
doi:10.1016/j.aorn.2017.05.005.
https://psnet.ahrq.gov/issue/improving-patient-safety-practicing-just-culture
The importance of just culture is widel…
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psnet.ahrq.gov/node/42971/psn-pdf
February 26, 2014 - Reducing central line–associated bloodstream infections
in North Carolina NICUs.
February 26, 2014
Fisher D, Cochran KM, Provost LP, et al. Reducing central line-associated bloodstream infections in North
Carolina NICUs. Pediatrics. 2013;132(6):e1664-71. doi:10.1542/peds.2013-2000.
https://psnet.ahrq.gov/issue/red…
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psnet.ahrq.gov/node/853251/psn-pdf
July 19, 2024 - Annual Speak Up Data Reports.
July 19, 2024
Stratford, London; The National Guardian.
https://psnet.ahrq.gov/issue/annual-speak-data-reports
Organizational efforts to collect and respond to the concerns of staff and patients are a cornerstone to
patient safety improvement despite challenges to implement them. This…
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psnet.ahrq.gov/node/38737/psn-pdf
July 13, 2009 - Reengineering hospital discharge: a protocol to improve
patient safety, reduce costs, and boost patient
satisfaction.
July 13, 2009
Clancy CM. Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and
boost patient satisfaction. Am J Med Qual. 2009;24(4):344-6. doi:10.1177/106286060…
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psnet.ahrq.gov/node/43302/psn-pdf
August 21, 2014 - A medication-based trigger tool to identify adverse events
in pediatric anesthesiology.
August 21, 2014
Taghon T, Elsey N, Miler V, et al. A medication-based trigger tool to identify adverse events in pediatric
anesthesiology. Jt Comm J Qual Patient Saf. 2014;40(7):326-334.
https://psnet.ahrq.gov/issue/medication-…
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psnet.ahrq.gov/node/43611/psn-pdf
December 19, 2014 - The Helsinki Declaration on Patient Safety in
Anaesthesiology: the past, present and future.
December 19, 2014
Mellin-Olsen J, Staender S. The Helsinki Declaration on Patient Safety in Anaesthesiology: the past,
present and future. Curr Opin Anaesthesiol. 2014;27(6):630-634. doi:10.1097/ACO.0000000000000131.
https…
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psnet.ahrq.gov/node/865933/psn-pdf
May 22, 2024 - Utilizing pharmacogenomic testing can improve
medication safety and prevent harm.
May 22, 2024
ISMP Medication Safety Alert! Acute Care. 2024;29(9):1-4.
https://psnet.ahrq.gov/issue/utilizing-pharmacogenomic-testing-can-improve-medication-safety-and-
prevent-harm
Pharmacogenomics (PGx) refers to the impact of gen…
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psnet.ahrq.gov/node/50705/psn-pdf
January 01, 2020 - Closing the loop with ambulatory staff on safety reports.
December 4, 2019
Williams S, Fiumara K, Kachalia A, et al. Closing the Loop with Ambulatory Staff on Safety Reports. Jt
Comm J Qual Saf. 2020;46(1):44-50. doi:10.1016/j.jcjq.2019.09.009.
https://psnet.ahrq.gov/issue/closing-loop-ambulatory-staff-safety-repor…
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psnet.ahrq.gov/node/842769/psn-pdf
January 18, 2023 - Production pressure and its relationship to safety: a
systematic review and future directions.
January 18, 2023
Hashemian SM, Triantis K. Production pressure and its relationship to safety: a systematic review and
future directions. Safety Sci. 2023;159:106045. doi:10.1016/j.ssci.2022.106045.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/35501/psn-pdf
June 15, 2011 - Ethical issues in patient safety.
June 15, 2011
Leape L. Ethical issues in patient safety. Thorac Surg Clin. 2005;15(4):493-501.
https://psnet.ahrq.gov/issue/ethical-issues-patient-safety
This commentary, written by patient safety expert Lucian Leape, begins with a retrospective view on the
birth of patient safety…
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psnet.ahrq.gov/node/44273/psn-pdf
July 01, 2015 - Current issues in patient safety in surgery: a review.
July 1, 2015
Kim FJ, da Silva RD, Gustafson D, et al. Current issues in patient safety in surgery: a review. Patient Saf
Surg. 2015;9:26. doi:10.1186/s13037-015-0067-4.
https://psnet.ahrq.gov/issue/current-issues-patient-safety-surgery-review
Universal strateg…
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psnet.ahrq.gov/node/46221/psn-pdf
July 02, 2017 - Tools and methods for quality improvement and patient
safety in perinatal care.
July 2, 2017
Nathan AT, Kaplan HC. Tools and methods for quality improvement and patient safety in perinatal care.
Semin Perinatol. 2017;41(3):142-150. doi:10.1053/j.semperi.2017.03.002.
https://psnet.ahrq.gov/issue/tools-and-methods-q…
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psnet.ahrq.gov/node/43022/psn-pdf
May 29, 2014 - Using simulation to improve root cause analysis of
adverse surgical outcomes.
May 29, 2014
Slakey DP, Simms ER, Rennie K, et al. Using simulation to improve root cause analysis of adverse surgical
outcomes. Int J Qual Health Care. 2014;26(2):144-50. doi:10.1093/intqhc/mzu011.
https://psnet.ahrq.gov/issue/using-sim…
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psnet.ahrq.gov/node/40002/psn-pdf
January 19, 2011 - Considerations for the design of safe and effective
consumer health IT applications in the home.
January 19, 2011
Zayas-Cabán T, Dixon BE. Considerations for the design of safe and effective consumer health IT
applications in the home. Qual Saf Health Care. 2010;19 Suppl 3:i61-i67. doi:10.1136/qshc.2010.041897.
ht…
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psnet.ahrq.gov/node/41190/psn-pdf
May 04, 2012 - Novel use of electronic whiteboard in the operating room
increases surgical team compliance with pre-incision
safety practices.
May 4, 2012
Mainthia R, Lockney T, Zotov A, et al. Novel use of electronic whiteboard in the operating room increases
surgical team compliance with pre-incision safety practices. Surgery.…
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psnet.ahrq.gov/node/35556/psn-pdf
May 27, 2011 - Improving patient safety using interactive, evidence-
based decision support tools.
May 27, 2011
Quinn MM, Mannion J. Improving patient safety using interactive, evidence-based decision support tools. Jt
Comm J Qual Patient Saf. 2005;31(12):678-683.
https://psnet.ahrq.gov/issue/improving-patient-safety-using-inter…
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psnet.ahrq.gov/node/36335/psn-pdf
February 01, 2011 - Rapid response teams—walk, don't run.
February 1, 2011
Winters BD, Pham JC, Pronovost PJ. Rapid Response Teams—Walk, Don't Run. JAMA. 2006;296(13).
doi:10.1001/jama.296.13.1645.
https://psnet.ahrq.gov/issue/rapid-response-teams-walk-dont-run
Rapid response teams (RRTs) have been widely advocated as a means of aver…
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psnet.ahrq.gov/node/37056/psn-pdf
February 24, 2011 - Use of multidisciplinary rounds to simultaneously
improve quality outcomes, enhance resident education,
and shorten length of stay.
February 24, 2011
O'Mahony S, Mazur E, Charney P, et al. Use of multidisciplinary rounds to simultaneously improve quality
outcomes, enhance resident education, and shorten length of …