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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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 …
  10. Psn-Pdf (pdf file)

    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 …
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…
  17. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
  18. Psn-Pdf (pdf file)

    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…
  19. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML …
  20. 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  View more articles from the same authors. Citation Text: Wachter R. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up. …

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