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psnet.ahrq.gov/node/35371/psn-pdf
June 17, 2014 - 2005 Quest for Quality Prize.
June 17, 2014
Association AH, Pharmacists AS of H-S, Networks H and H. Medication Safety Issue Brief. Bar Code
implementation strategies. Hosp Health Netw. 2005;79(7):65-66.
https://psnet.ahrq.gov/issue/2005-quest-quality-prize
This article highlights successful practices of the 2005 …
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psnet.ahrq.gov/node/40813/psn-pdf
July 19, 2017 - How to develop an effective obstetric checklist.
July 19, 2017
Fausett B, Propst A, Van Doren K, et al. How to develop an effective obstetric checklist. Am J Obstet
Gynecol. 2011;205(3):165-70. doi:10.1016/j.ajog.2011.06.003.
https://psnet.ahrq.gov/issue/how-develop-effective-obstetric-checklist
This commentary di…
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psnet.ahrq.gov/node/38344/psn-pdf
January 21, 2009 - The error of omission: a simple checklist approach for
improving operating room safety.
January 21, 2009
Rosenfield LK, Chang DS. The error of omission: a simple checklist approach for improving operating room
safety. Plast Reconstr Surg. 2009;123(1):399-402. doi:10.1097/PRS.0b013e318193472f.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/35124/psn-pdf
June 29, 2005 - JCAHO proposal for patient-centered care brings concept
to mainstream healthcare settings.
June 29, 2005
ECRI. Risk Management Reporter. June 2005.
https://psnet.ahrq.gov/issue/jcaho-proposal-patient-centered-care-brings-concept-mainstream-healthcare-
settings
This commentary provides a definition of patient-cent…
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psnet.ahrq.gov/node/41620/psn-pdf
August 22, 2012 - Improving care transitions: optimizing medication
reconciliation.
August 22, 2012
Association AP, Pharmacists AS of H-S, Steeb D, et al. Improving care transitions: optimizing medication
reconciliation. J Am Pharm Assoc (2003). 2012;52(4):e43-e52. doi:10.1331/JAPhA.2012.12527.
https://psnet.ahrq.gov/issue/improvin…
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psnet.ahrq.gov/node/38021/psn-pdf
August 27, 2008 - A review of the current evidence base for significant
event analysis.
August 27, 2008
Bowie P, Pope L, Lough M. A review of the current evidence base for significant event analysis. J Eval Clin
Pract. 2008;14(4):520-36. doi:10.1111/j.1365-2753.2007.00908.x.
https://psnet.ahrq.gov/issue/review-current-evidence-base…
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psnet.ahrq.gov/node/33852/psn-pdf
January 01, 2017 - Patient Engagement in Safety
January 1, 2017
Stern RJ, Sarkar U. Patient Engagement in Safety. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/patient-engagement-safety
Annual Perspective 2017
Background
In the past 2 decades, patient engagement in safety has evolved from obscurity to maturity. The Ins…
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psnet.ahrq.gov/node/37931/psn-pdf
September 25, 2008 - Can a structured checklist prevent problems with
laparoscopic equipment?
September 25, 2008
Verdaasdonk EGG, Stassen LPS, Hoffmann WF, et al. Can a structured checklist prevent problems with
laparoscopic equipment? Surg Endosc. 2008;22(10):2238-43. doi:10.1007/s00464-008-0029-3.
https://psnet.ahrq.gov/issue/can-st…
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psnet.ahrq.gov/node/34138/psn-pdf
January 20, 2016 - National Quality Forum.
January 20, 2016
1099 14th Street NW, Suite 500, Washington DC 20005.
https://psnet.ahrq.gov/issue/national-quality-forum
The National Quality Forum (NQF) is a private, not-for-profit membership organization created to develop
and implement a national strategy for quality and safety measure…
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psnet.ahrq.gov/node/40829/psn-pdf
January 05, 2014 - Guide to Reducing Unintended Consequences of
Electronic Health Records.
January 5, 2014
Jones SS, Koppel R, Ridgely MS, Palen TE, Wu S, Harrison MI. Rockville, MD: Agency for Healthcare
Research and Quality; August 2011.
https://psnet.ahrq.gov/issue/guide-reducing-unintended-consequences-electronic-health-records
…
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psnet.ahrq.gov/node/38677/psn-pdf
August 18, 2010 - Impact of a computerized physician order-entry system.
August 18, 2010
Stone WM, Smith BE, Shaft JD, et al. Impact of a computerized physician order-entry system. J Am Coll
Surg. 2009;208(5):960-7; discussion 967-9. doi:10.1016/j.jamcollsurg.2009.01.042.
https://psnet.ahrq.gov/issue/impact-computerized-physician-or…
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psnet.ahrq.gov/node/47556/psn-pdf
November 28, 2018 - Improving Diagnosis.
November 28, 2018
Deutsch E, ed. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):1-70.
https://psnet.ahrq.gov/issue/improving-diagnosis
This special issue raises awareness of challenges to reducing diagnostic error. Articles discuss insights
from experts about how to improve diagnosis, t…
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psnet.ahrq.gov/node/41411/psn-pdf
October 19, 2012 - Minnesota Hospital Association Statewide Project: SAFE
from FALLS.
October 19, 2012
Apold J, Quigley PA. Minnesota Hospital Association Statewide Project: SAFE from FALLS. J Nurs Care
Qual. 2012;27(4):299-306. doi:10.1097/NCQ.0b013e3182599d1b.
https://psnet.ahrq.gov/issue/minnesota-hospital-association-statewide-p…
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psnet.ahrq.gov/node/50633/psn-pdf
November 06, 2019 - Findings of Two Inaugural Leapfrog Surveys 2019.
November 6, 2019
Washington DC: Leapfrog Group; 2019.
https://psnet.ahrq.gov/issue/findings-two-inaugural-leapfrog-surveys-2019
Ambulatory surgery centers (ASC) are established venues for surgical care despite engagement in
assessment to ensure their safety. This re…
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psnet.ahrq.gov/node/35373/psn-pdf
July 20, 2009 - Medical groups' adoption of electronic health records and
information systems.
July 20, 2009
Gans DN, Kralewski J, Hammons T, et al. Medical Groups’ Adoption Of Electronic Health Records And
Information Systems. Health Aff. 2005;24(5):1323-1333. doi:10.1377/hlthaff.24.5.1323.
https://psnet.ahrq.gov/issue/medical-g…
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psnet.ahrq.gov/node/41972/psn-pdf
January 23, 2013 - Impact of a pharmacotherapy alerting system on
medication errors.
January 23, 2013
Natali BJ, Varkey AC, Garey KW, et al. Impact of a pharmacotherapy alerting system on medication errors.
American Journal of Health-System Pharmacy. 2012;70(1). doi:10.2146/ajhp120126.
https://psnet.ahrq.gov/issue/impact-pharmacothe…
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psnet.ahrq.gov/node/42714/psn-pdf
August 19, 2017 - SWITCH for safety: perioperative hand-off tools.
August 19, 2017
Johnson F, Logsdon P, Fournier K, et al. SWITCH for safety: Perioperative hand-off tools. AORN J.
2013;98(5):494-504; quiz 505-7. doi:10.1016/j.aorn.2013.08.016.
https://psnet.ahrq.gov/issue/switch-safety-perioperative-hand-tools
This commentary desc…
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psnet.ahrq.gov/node/35085/psn-pdf
July 24, 2018 - Working Knowledge: How Organizations Manage What
They Know.
July 24, 2018
Davenport TH, Prusak L. Boston MA: Harvard Business School Press; 1998. ISBN: 0875846556.
https://psnet.ahrq.gov/issue/working-knowledge-how-organizations-manage-what-they-know
Two innovators in management consulting introduce core concepts …
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psnet.ahrq.gov/node/33902/psn-pdf
December 22, 2014 - National Quality Measures Clearinghouse (NQMC).
December 22, 2014
Agency for Healthcare Research and Quality. 1998-2018.
https://psnet.ahrq.gov/issue/national-quality-measures-clearinghouse-nqmc
This web-accessible database provided access to evidence-based quality measures and measure sets.
The mission of the Nat…
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psnet.ahrq.gov/node/35618/psn-pdf
June 24, 2010 - Using a computerized sign-out system to improve
physician–nurse communication.
June 24, 2010
Sidlow R, Katz-Sidlow RJ. Using a computerized sign-out system to improve physician-nurse
communication. Jt Comm J Qual Patient Saf. 2006;32(1):32-36.
https://psnet.ahrq.gov/issue/using-computerized-sign-out-system-improve…