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psnet.ahrq.gov/node/40139/psn-pdf
January 22, 2017 - Standardizing hospital discharge planning at the Mayo
Clinic.
January 22, 2017
Holland DE, Hemann MA. Standardizing hospital discharge planning at the Mayo Clinic. Jt Comm J Qual
Patient Saf. 2011;37(1):29-36.
https://psnet.ahrq.gov/issue/standardizing-hospital-discharge-planning-mayo-clinic
Implementation of a s…
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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…
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psnet.ahrq.gov/node/35517/psn-pdf
November 17, 2016 - Joint Commission Journal on Quality and Patient Safety.
November 17, 2016
Baker D, ed. Oakbrook Terrace, IL: Joint Commission. ISSN: 1553-7250.
https://psnet.ahrq.gov/issue/joint-commission-journal-quality-and-patient-safety
This monthly, peer-reviewed journal provides both empirical studies and practical instructi…
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psnet.ahrq.gov/node/39538/psn-pdf
May 19, 2010 - CPOE: strategies for success.
May 19, 2010
Manor PJ. CPOE: Strategies for success. Nurs Manage. 2010;41(5):18-20.
doi:10.1097/01.NUMA.0000372028.99240.7f.
https://psnet.ahrq.gov/issue/cpoe-strategies-success
This commentary reviews tactics to engage nurses in computerized provider order entry (CPOE)
implementatio…
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psnet.ahrq.gov/node/42167/psn-pdf
April 03, 2013 - Engaging Patients in Improving Ambulatory Care.
April 3, 2013
Aligning Forces for Quality. Princeton, NJ: Robert Wood Johnson Foundation; 2013.
https://psnet.ahrq.gov/issue/engaging-patients-improving-ambulatory-care
This compendium includes strategies and tools to engage patients in health care improvement that ha…
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psnet.ahrq.gov/node/37753/psn-pdf
May 02, 2018 - Some red rules shouldn't rule in hospitals.
May 2, 2018
ISMP Medication Safety Alert! Acute Care Edition. April 24, 2008;13:1-3.
https://psnet.ahrq.gov/issue/some-red-rules-shouldnt-rule-hospitals
This article provides a set of criteria for health care professionals to develop and implement red rules as an
effecti…
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psnet.ahrq.gov/node/40887/psn-pdf
June 27, 2018 - Daily check-in for safety: from best practice to common
practice.
June 27, 2018
Stockmeier C, Clapper C. Patient Saf Qual Healthc. September/October 2011;8:30-31,34-36.
https://psnet.ahrq.gov/issue/daily-check-safety-best-practice-common-practice
This article reports on organizations that have implemented daily ch…
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psnet.ahrq.gov/node/35422/psn-pdf
June 17, 2014 - Medication safety issue brief. Medication reconciliation.
June 17, 2014
Hosp Health Netw. 2005 Sep;79(9):33-34.
https://psnet.ahrq.gov/issue/medication-safety-issue-brief-medication-reconciliation
This issue brief provides case studies from hospitals that have successfully implemented medication
reconciliation pro…
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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 …
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psnet.ahrq.gov/node/35190/psn-pdf
June 17, 2014 - The quality connection.
June 17, 2014
Solovy A. The 100 most wired 2005: the quality connection. Hospitals Health Network. 2005;79(7):38-50, 2.
https://psnet.ahrq.gov/issue/quality-connection
This article reports on the results of Hospitals & Health Networks' 2005 Most Wired Survey and
Benchmarking Study. Results …
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psnet.ahrq.gov/node/39815/psn-pdf
March 18, 2011 - Introducing new technology safely.
March 18, 2011
Mytton OT, Velazquez A, Banken R, et al. Introducing new technology safely. Qual Saf Health Care.
2010;19 Suppl 2:i9-14. doi:10.1136/qshc.2009.038554.
https://psnet.ahrq.gov/issue/introducing-new-technology-safely
This report describes the distinction between techn…
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psnet.ahrq.gov/node/35937/psn-pdf
June 19, 2007 - Ounce of prevention: to reduce errors, hospitals
prescribe innovative designs.
June 19, 2007
Naik G. Wall Street Journal. May 8, 2006; A1.
https://psnet.ahrq.gov/issue/ounce-prevention-reduce-errors-hospitals-prescribe-innovative-designs
This article reports on innovations implemented at a Wisconsin hospital to im…
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psnet.ahrq.gov/node/36067/psn-pdf
September 28, 2010 - Operating room briefings.
September 28, 2010
Makary MA, Holzmueller CG, Sexton B, et al. Operating room debriefings. Jt Comm J Qual Patient Saf.
2006;32(7):407-410, 357.
https://psnet.ahrq.gov/issue/operating-room-briefings
The authors describe a postoperative debriefing tool used by surgical teams at Johns Hopkin…
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psnet.ahrq.gov/node/36598/psn-pdf
June 30, 2011 - E-prescribing first step to improved safety.
June 30, 2011
Finkelstein JB. E-prescribing first step to improved safety. Journal of the National Cancer Institute.
2006;98(24):1763-5.
https://psnet.ahrq.gov/issue/e-prescribing-first-step-improved-safety
This article discusses changes implemented at Dana-Farber Cance…
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psnet.ahrq.gov/node/39041/psn-pdf
October 21, 2009 - The OR and a "just culture."
October 21, 2009
Hamlin L. The OR and a "just culture". AORN J. 2009;90(4):495-498. doi:10.1016/j.aorn.2009.09.003.
https://psnet.ahrq.gov/issue/or-and-just-culture
To illustrate the value of just culture implementation, this piece describes a hypothetical scenario involving
the WHO Sa…
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psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
January 07, 2015 - Haste Makes Care Unsafe
Citation Text:
Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
February 12, 2020 - Diagnostic Overshadowing Dangers
Citation Text:
Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/33743/psn-pdf
December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing
and Treating Delirium in the Intensive Care Unit
December 1, 2012
Vasilevskis EE, Ely WE, Dittus RS. Quality and Safety Challenges in Critical Care: Preventing and Treating
Delirium in the Intensive Care Unit. PSNet [internet]. 2012.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery
January 19, 2016 - Bowel Injury After Laparoscopic Surgery
Citation Text:
Moorthy K. Bowel Injury After Laparoscopic Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom
December 01, 2005 - An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up
Robert M. Wachter, MD | June 1, 2012
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Citation Text:
Wachter R. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up. …