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psnet.ahrq.gov/node/42061/psn-pdf
October 05, 2015 - Preventing Falls in Hospitals: A Toolkit for Improving
Quality of Care.
October 5, 2015
Ganz DA, Huang C, Saliba D, et al. Rockville, MD: Agency for Healthcare Research and Quality; January
2013. AHRQ Publication No. 13-0015-EF.
https://psnet.ahrq.gov/issue/preventing-falls-hospitals-toolkit-improving-quality-care…
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psnet.ahrq.gov/node/40774/psn-pdf
September 14, 2011 - A system-wide initiative to prevent retained vaginal
sponges.
September 14, 2011
Chagolla BA, Gibbs VC, Keats JP, et al. A system-wide initiative to prevent retained vaginal sponges. MCN
Am J Matern Child Nurs. 2011;36(5):312-317. doi:10.1097/NMC.0b013e31822ab204.
https://psnet.ahrq.gov/issue/system-wide-initiativ…
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psnet.ahrq.gov/node/857580/psn-pdf
August 09, 2024 - Patient Safety Research Summaries.
August 9, 2024
Rockville, MD: Agency for Healthcare Research and Quality; 2023-2024.
https://psnet.ahrq.gov/issue/patient-safety-research-summaries
The application of evidence in real situations helps to embed innovation across systems and sustain care
improvement. This col…
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psnet.ahrq.gov/node/36550/psn-pdf
January 12, 2011 - Effects of technological interventions on the safety of a
medication-use system.
January 12, 2011
Skibinski K, White BA, Lin LI-K, et al. Effects of technological interventions on the safety of a medication-
use system. Am J Health Syst Pharm. 2007;64(1):90-6.
https://psnet.ahrq.gov/issue/effects-technological-int…
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psnet.ahrq.gov/node/36077/psn-pdf
July 05, 2006 - Perinatal patient safety from the perspective of nurse
executives: a round table discussion.
July 5, 2006
Thorman KE; Capitulo KL; Dubow J; Hanold K; Noonan M; Wehmeyer J.
https://psnet.ahrq.gov/issue/perinatal-patient-safety-perspective-nurse-executives-round-table-discussion
The authors summarize a discussion be…
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psnet.ahrq.gov/node/36594/psn-pdf
May 27, 2011 - Right tech dose helps medicine go down.
May 27, 2011
Patton S. CIO Magazine. July 12, 2006.
https://psnet.ahrq.gov/issue/right-tech-dose-helps-medicine-go-down
The author describes some common mistakes involving the design and launch of computerized physician
order entry (CPOE) initiatives and provides sugges…
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psnet.ahrq.gov/node/34940/psn-pdf
June 23, 2009 - Medication safety: look-alike/sound-alike drugs in home
care.
June 23, 2009
Friedman MMG. Medication safety: look-alike/sound-alike drugs in home care. Home Healthc Nurse.
2005;23(4):243-253.
https://psnet.ahrq.gov/issue/medication-safety-look-alikesound-alike-drugs-home-care
This article reviews the National Pat…
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psnet.ahrq.gov/node/40751/psn-pdf
September 07, 2011 - Developing a programme for medication reconciliation at
the time of admission into hospital.
September 7, 2011
Manzorro ÁG, Zoni AC, Rieiro CR, et al. Developing a programme for medication reconciliation at the time
of admission into hospital. Int J Clin Pharm. 2011;33(4):603-9. doi:10.1007/s11096-011-9530-1.
http…
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psnet.ahrq.gov/node/46576/psn-pdf
October 25, 2017 - Curing our diagnostic disorder.
October 25, 2017
Laposata M. The Pathologist. September 2017;(34):18-27.
https://psnet.ahrq.gov/issue/curing-our-diagnostic-disorder
Diagnostic improvement is gaining recognition as an important goal in health care. This magazine article
reports on one pathologist's efforts to devel…
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psnet.ahrq.gov/node/41854/psn-pdf
September 24, 2016 - Reducing interruptions to improve medication safety.
September 24, 2016
Freeman R, McKee S, Lee-Lehner B, et al. Reducing interruptions to improve medication safety. J Nurs
Care Qual. 2013;28(2):176-85. doi:10.1097/NCQ.0b013e318275ac3e.
https://psnet.ahrq.gov/issue/reducing-interruptions-improve-medication-safety
…
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psnet.ahrq.gov/node/36173/psn-pdf
September 29, 2010 - The need for organizational change in patient safety
initiatives.
September 29, 2010
Anderson J, Ramanujam R, Hensel D, et al. The need for organizational change in patient safety initiatives.
Int J Med Inform. 2006;75(12):809-17.
https://psnet.ahrq.gov/issue/need-organizational-change-patient-safety-initiatives
…
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psnet.ahrq.gov/node/35686/psn-pdf
December 23, 2016 - Using medication reconciliation to prevent errors.
December 23, 2016
Using medication reconciliation to prevent errors. Sentinel Event Alert. 2006;35(35):1-4.
https://psnet.ahrq.gov/issue/using-medication-reconciliation-prevent-errors
This alert emphasizes the importance of reconciling medications and supports impl…
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psnet.ahrq.gov/node/37157/psn-pdf
October 06, 2011 - Nurses' satisfaction with medication administration point-
of-care technology.
October 6, 2011
Hurley A, Bane A, Fotakis S, et al. Nurses' satisfaction with medication administration point-of-care
technology. J Nurs Adm. 2007;37(7-8):343-349.
https://psnet.ahrq.gov/issue/nurses-satisfaction-medication-administrati…
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psnet.ahrq.gov/node/38218/psn-pdf
July 05, 2013 - Bedside handover: quality improvement strategy to
"transform care at the bedside."
July 5, 2013
Chaboyer W, McMurray A, Johnson J, et al. Bedside handover: quality improvement strategy to "transform
care at the bedside". J Nurs Care Qual. 2009;24(2):136-42. doi:10.1097/01.NCQ.0000347450.90676.d9.
https://psnet.ahr…
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psnet.ahrq.gov/node/41090/psn-pdf
January 25, 2012 - Early warning systems: the next level of rapid response.
January 25, 2012
Duncan KD, McMullan C, Mills BM. Early warning systems: the next level of rapid response. Nursing
(Brux). 2012;42(2):38-45. doi:10.1097/01.NURSE.0000410304.26165.33.
https://psnet.ahrq.gov/issue/early-warning-systems-next-level-rapid-response…
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psnet.ahrq.gov/node/37369/psn-pdf
January 22, 2017 - Improving the Health Care Work Environment.
January 22, 2017
Jt Comm J Qual Saf. 2007;33(11 supp):s2-s84.
https://psnet.ahrq.gov/issue/improving-health-care-work-environment
This supplement includes articles regarding several research projects that explore organizational climate,
hospital staffing, and work…
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psnet.ahrq.gov/node/37860/psn-pdf
January 15, 2009 - Economic evaluations of maintaining patient safety
systems in teaching hospitals.
January 15, 2009
Fukuda H, Imanaka Y, Hirose M, et al. Economic evaluations of maintaining patient safety systems in
teaching hospitals. Health Policy (New York). 2008;88(2-3):381-91. doi:10.1016/j.healthpol.2008.04.004.
https://psne…
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psnet.ahrq.gov/node/867770/psn-pdf
March 01, 2022 - Toolkit for Decolonization of Non-ICU Patients with
Devices.
March 1, 2022
Agency for Healthcare Research and Quality. Toolkit for Decolonization of Non-ICU Patients with Devices.
https://psnet.ahrq.gov/issue/toolkit-decolonization-non-icu-patients-devices
Healthcare associated infection is a persistent contributo…
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psnet.ahrq.gov/node/36451/psn-pdf
December 22, 2010 - Surgical site verification: A through Z.
December 22, 2010
Dunn D. Surgical site verification: A through Z. J Perianesth Nurs. 2006;21(5):317-28; quiz 329-31.
https://psnet.ahrq.gov/issue/surgical-site-verification-through-z
The author explains the Joint Commission on Accreditation of Healthcare Organizations' Univ…
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psnet.ahrq.gov/node/40269/psn-pdf
January 01, 2016 - Rapid response systems in the Netherlands.
March 9, 2011
Ludikhuize J, Hamming A, De Jonge E, et al. Rapid Response Systems in the Netherlands. Jt Comm J
Qual Patient Saf. 2016;37(3):138-149. doi:10.1016/s1553-7250(11)37017-1.
https://psnet.ahrq.gov/issue/rapid-response-systems-netherlands
Nearly 80% of Dutch hosp…