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psnet.ahrq.gov/node/35249/psn-pdf
March 04, 2011 - The patient safety story.
March 4, 2011
Elwyn G, Corrigan JM. The patient safety story. BMJ. 2005;331(7512):302-304.
doi:10.1136/bmj.38562.690104.43.
https://psnet.ahrq.gov/issue/patient-safety-story
The authors provide a brief history of the patient safety movement and insights into why the time is right to
impl…
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psnet.ahrq.gov/perspective/conversation-suchi-saria-phd
March 27, 2024 - In a way it's great, because it's building organizational muscle for implementing electronic systems
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psnet.ahrq.gov/node/37085/psn-pdf
July 15, 2013 - Critical Care Safety: Essentials for ICU Patient Care and
Technology.
July 15, 2013
Plymouth Meeting PA: ECRI Institute; 2007. ISBN 9780977914258.
https://psnet.ahrq.gov/issue/critical-care-safety-essentials-icu-patient-care-and-technology
This guide provides comprehensive tools for assessment, training, and imple…
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psnet.ahrq.gov/node/39589/psn-pdf
February 13, 2018 - Common cause analysis.
February 13, 2018
Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.
https://psnet.ahrq.gov/issue/common-cause-analysis
This article describes how one health care system used a multi-event analysis process to identify
medication errors, implement system-level improvements, a…
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psnet.ahrq.gov/node/40703/psn-pdf
August 17, 2011 - Washington Hospital Center safety program seeks to
catch 'near-misses.'
August 17, 2011
Sun LH.
https://psnet.ahrq.gov/issue/washington-hospital-center-safety-program-seeks-catch-near-misses
This newspaper article reports on one hospital's implementation of an alert system designed to encourage
frontline personne…
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psnet.ahrq.gov/node/38230/psn-pdf
August 11, 2010 - The Patient Safety Leadership WalkRounds Guide.
August 11, 2010
Frankel AS, Grillo S, Pittman MA. Chicago, IL: Health Research and Educational Trust; 2006.
https://psnet.ahrq.gov/issue/patient-safety-leadership-walkrounds-guide
This booklet provides information on the implementation of a WalkRounds program as a cul…
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psnet.ahrq.gov/node/42718/psn-pdf
September 17, 2018 - A Culture of Safety in EMS Systems.
September 17, 2018
Irving, TX: American College of Emergency Physicians; 2014.
https://psnet.ahrq.gov/issue/culture-safety-ems-systems
This guidance recognizes risks associated with emergency medical services and provides
recommendations to support the implementation of a safety…
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psnet.ahrq.gov/node/37229/psn-pdf
November 28, 2007 - Many Mass. hospitals will pay for errors.
November 28, 2007
Kowalczyk L.
https://psnet.ahrq.gov/issue/many-mass-hospitals-will-pay-errors
This article reports on how numerous Massachusetts hospitals have implemented policies to waive charges
for the set of serious errors categorized as never events.
https://psnet…
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psnet.ahrq.gov/node/35702/psn-pdf
May 30, 2008 - The Prescription Infrastructre: Are We Ready for
ePrescribing?
May 30, 2008
Sarasohn-Kahn J, Holt M. Oakland, CA: California Healthcare Foundation; 2006. ISBN 1933795026.
https://psnet.ahrq.gov/issue/prescription-infrastructre-are-we-ready-eprescribing
This report outlines the prescription process and the potentia…
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psnet.ahrq.gov/node/50844/psn-pdf
January 29, 2020 - Improving Patient Safety and Team Communication
through Daily Huddles
January 29, 2020
Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet].
2020.
https://psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
Background
Communicat…
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psnet.ahrq.gov/node/36869/psn-pdf
August 31, 2011 - An extra dose of safety.
August 31, 2011
An extra dose of safety. Installation of a bar-coding system drives an entire workflow redesign at a non-
profit hospital and healthcare network. Health management technology. 2007;28(4):30-2, 34.
https://psnet.ahrq.gov/issue/extra-dose-safety
This article describes a healt…
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psnet.ahrq.gov/node/41365/psn-pdf
May 09, 2012 - Patient safety: break the silence.
May 9, 2012
Johnson HL, Kimsey D. Patient safety: break the silence. AORN J. 2012;95(5):591-601.
doi:10.1016/j.aorn.2012.03.002.
https://psnet.ahrq.gov/issue/patient-safety-break-silence
This commentary describes the development, implementation, and impact of a team-based safety …
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psnet.ahrq.gov/node/36757/psn-pdf
August 09, 2011 - Medication bar coding: to scan or not to scan?
August 9, 2011
Galvin L, McBeth S, Hasdorff C, et al. Medication bar coding: to scan or not to scan? Comput Inform Nurs.
2007;25(2):86-92.
https://psnet.ahrq.gov/issue/medication-bar-coding-scan-or-not-scan
The authors describe the implementation of a bedside medicati…
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psnet.ahrq.gov/node/33997/psn-pdf
March 17, 2011 - Maryland/DC Patient Safety Coalition.
March 17, 2011
https://psnet.ahrq.gov/issue/marylanddc-patient-safety-coalition
The Maryland Patient Safety Center facilitates the study of unsafe practices and the implementation of
practical improvements to prevent errors. The center is a collaboration of two organizations th…
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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/841493/psn-pdf
December 14, 2022 - Telehealth and Patient Safety.
December 14, 2022
O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/telehealth-and-patient-safety
Background
In recent years, telehealth, or the delivery of healthcare over a distance using telecommunications
techno…
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psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
June 01, 2014 - Mixup Beyond the Medication Label
Citation Text:
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
May 01, 2014 - In most institutions where you are promoting hand hygiene, it is clear that you are also implementing
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psnet.ahrq.gov/curated-library/diagnostic-safety-improvement
November 10, 2025 - The report includes comprehensive, broad-scope, actionable, and specific recommendations for implementing
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psnet.ahrq.gov/node/49801/psn-pdf
August 01, 2017 - Given that many surgical deaths may be avoidable (4-9), hospitals are implementing
care protocols to