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psnet.ahrq.gov/node/35395/psn-pdf
September 10, 2009 - Toward a theoretical approach to medical error reporting
system research and design.
September 10, 2009
Karsh B-T, Escoto KH, Beasley JW, et al. Toward a theoretical approach to medical error reporting system
research and design. Appl Ergon. 2006;37(3):283-95.
https://psnet.ahrq.gov/issue/toward-theoretical-approa…
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psnet.ahrq.gov/node/37558/psn-pdf
July 05, 2013 - Patient safety and quality improvement.
July 5, 2013
Agency for Healthcare Research and Quality. Fed Register. February 12, 2008;73(29):8112-8183.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement
These proposed rules seek to support the implementation of portions of the Patient Safety and Quality…
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psnet.ahrq.gov/node/41728/psn-pdf
January 18, 2013 - Who's covering our loved ones: surprising barriers in the
sign-out process.
January 18, 2013
Antonoff MB, Berdan EA, Kirchner VA, et al. Who's covering our loved ones: surprising barriers in the sign-
out process. Am J Surg. 2013;205(1):77-84. doi:10.1016/j.amjsurg.2012.05.009.
https://psnet.ahrq.gov/issue/whos-co…
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psnet.ahrq.gov/node/39344/psn-pdf
March 03, 2010 - Mistake-proofing healthcare: why stopping processes
may be a good start.
March 3, 2010
Grout JR, Toussaint JS. Mistake-proofing healthcare: Why stopping processes may be a good start. Bus
Horiz. 2009;53(2):149-156. doi:10.1016/j.bushor.2009.10.007.
https://psnet.ahrq.gov/issue/mistake-proofing-healthcare-why-stopp…
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psnet.ahrq.gov/node/50771/psn-pdf
May 29, 2024 - AHRQ Health Literacy Universal Precautions Toolkit. 3rd
edition.
May 29, 2024
Brach C, ed. Rockville, MD: Agency for Healthcare Research and Quality; March 2024. AHRQ Publication
No. 15-0023-EF.
https://psnet.ahrq.gov/issue/ahrq-health-literacy-universal-precautions-toolkit-2nd-edition
The AHRQ Health Literacy Un…
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psnet.ahrq.gov/node/41075/psn-pdf
January 18, 2012 - Wide heart monitor use tied to missed alarms.
January 18, 2012
Funk M, Winkler CG, May JL, et al. Unnecessary arrhythmia monitoring and underutilization of ischemia
and QT interval monitoring in current clinical practice: baseline results of the Practical Use of the Latest
Standards for Electrocardiography trial. J…
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psnet.ahrq.gov/node/42826/psn-pdf
December 18, 2013 - Improvement of medication event interventions through
use of an electronic database.
December 18, 2013
Merandi J, Morvay S, Lewe D, et al. Improvement of medication event interventions through use of an
electronic database. Am J Health Syst Pharm. 2013;70(19):1708-14. doi:10.2146/ajhp130021.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/43891/psn-pdf
September 29, 2017 - AHRQ announces interest in research on health IT safety.
September 29, 2017
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. March 9, 2016.
Publication No. NOT-HS-16-009.
https://psnet.ahrq.gov/issue/ahrq-announces-interest-research-health-it-safety
This announcement highlights A…
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psnet.ahrq.gov/node/45084/psn-pdf
April 27, 2016 - Nurses say stress interferes with caring for their patients.
April 27, 2016
Yu A. Health Shots. National Public Radio. April 15, 2016.
https://psnet.ahrq.gov/issue/nurses-say-stress-interferes-caring-their-patients
Many health care professionals exhibit symptoms of burnout, which may impair their ability to maintai…
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psnet.ahrq.gov/node/50715/psn-pdf
December 04, 2019 - Quality and Safety of Healthcare in Switzerland.
December 4, 2019
Vincent C, Staines A. Bern, Switzerland: Federal Department of Home Affairs, Federal Office of Public
Health; 2019.
https://psnet.ahrq.gov/issue/quality-and-safety-healthcare-switzerland
Patient safety is a goal for countries worldwide. This report …
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psnet.ahrq.gov/node/37844/psn-pdf
June 18, 2008 - Effect of ACGME duty hours on attending physician
teaching and satisfaction.
June 18, 2008
Arora V, Meltzer DO. Effect of ACGME duty hours on attending physician teaching and satisfaction. Arch
Intern Med. 2008;168(11):1226-8. doi:10.1001/archinte.168.11.1226.
https://psnet.ahrq.gov/issue/effect-acgme-duty-hours-a…
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psnet.ahrq.gov/node/36542/psn-pdf
August 06, 2008 - Pediatric rapid response teams in the academic medical
center.
August 6, 2008
Mistry KP, Turi J, Hueckel RM, et al. Pediatric Rapid Response Teams in the Academic Medical Center.
Clin Pediatr Emerg Med. 2006;7(4). doi:10.1016/j.cpem.2006.08.010.
https://psnet.ahrq.gov/issue/pediatric-rapid-response-teams-academic-…
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psnet.ahrq.gov/node/35125/psn-pdf
June 29, 2005 - 2005 Annual Patient Safety and Health Information
Technology Conference: Making the Health Care System
Safer through Implementation and Innovation.
June 29, 2005
Agency for Healthcare Research and Quality
https://psnet.ahrq.gov/issue/2005-annual-patient-safety-and-health-information-technology-conference-
making-…
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psnet.ahrq.gov/node/36636/psn-pdf
January 14, 2011 - Nursing home administrators' opinions of the resident
safety culture in nursing homes.
January 14, 2011
Castle NG, Handler S, Engberg J, et al. Nursing home administrators' opinions of the resident safety
culture in nursing homes. Health Care Manage Rev. 2007;32(1):66-76.
https://psnet.ahrq.gov/issue/nursing-home-…
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psnet.ahrq.gov/node/43216/psn-pdf
June 25, 2014 - Banning the handshake from the health care setting.
June 25, 2014
Sklansky M, Nadkarni N, Ramirez-Avila L. Banning the handshake from the health care setting. JAMA.
2014;311(24):2477-8.
https://psnet.ahrq.gov/issue/banning-handshake-health-care-setting
Hand hygiene is an important practice that prevents transmissi…
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psnet.ahrq.gov/node/47280/psn-pdf
October 15, 2018 - Master of Healthcare Quality and Safety.
October 15, 2018
Harvard Medical School.
https://psnet.ahrq.gov/issue/master-healthcare-quality-and-safety
This one-year degree program will train clinicians and health care executives to lead safety and quality
improvement initiatives. Participants will learn how to develo…
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psnet.ahrq.gov/node/39175/psn-pdf
December 16, 2009 - Impact of a standard medication chart on prescribing
errors: a before-and-after audit.
December 16, 2009
Coombes ID, Stowasser DA, Reid C, et al. Impact of a standard medication chart on prescribing errors: a
before-and-after audit. Qual Saf Health Care. 2009;18(6):478-85. doi:10.1136/qshc.2007.025296.
https://psn…
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psnet.ahrq.gov/node/37788/psn-pdf
May 28, 2008 - Durable improvements in efficiency, safety, and
satisfaction in the operating room.
May 28, 2008
Heslin MJ, Doster BE, Daily SL, et al. Durable improvements in efficiency, safety, and satisfaction in the
operating room. J Am Coll Surg. 2008;206(5):1083-9; discussion 1089-90.
doi:10.1016/j.jamcollsurg.2008.02.006.
…
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psnet.ahrq.gov/node/43233/psn-pdf
June 17, 2014 - Quality and safety education for nurses: a nursing
leadership skills exercise.
June 17, 2014
Harrison EM. Quality and safety education for nurses: a nursing leadership skills exercise. J Nurs Educ.
2014;53(6):356-361. doi:10.3928/01484834-20140512-01.
https://psnet.ahrq.gov/issue/quality-and-safety-education-nurse…
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psnet.ahrq.gov/node/40500/psn-pdf
June 01, 2011 - Meaningful use and certification of health information
technology: what about safety?
June 1, 2011
Hoffman S, Podgurski A. Meaningful use and certification of health information technology: what about
safety? J Law Med Ethics. 2011;39(suppl 1):77-80. doi:10.1111/j.1748-720X.2011.00572.x.
https://psnet.ahrq.gov/iss…