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psnet.ahrq.gov/node/40517/psn-pdf
June 08, 2011 - Learning safe prescribing during post-take ward rounds.
June 8, 2011
Conroy-Smith E, Herring R, Caldwell G. Learning safe prescribing during post-take ward rounds. The
clinical teacher. 2011;8(2):75-8. doi:10.1111/j.1743-498X.2011.00432.x.
https://psnet.ahrq.gov/issue/learning-safe-prescribing-during-post-take-ward…
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psnet.ahrq.gov/node/35980/psn-pdf
January 01, 2019 - The development of the National Reporting and Learning
System in England and Wales, 2001-2005.
December 23, 2012
Williams SK, Osborn SS. The development of the National Reporting and Learning System in England and
Wales, 2001–2005. Med J Aust. 2019;184(S10) (S10):s65-s68. doi:10.5694/j.1326-5377.2006.tb00366.x.
ht…
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psnet.ahrq.gov/node/41261/psn-pdf
May 04, 2012 - Case-based learning for patient safety: the Lessons
Learnt program for UK junior doctors.
May 4, 2012
Ahmed M, Arora S, Baker P, et al. Case-based learning for patient safety: the Lessons Learnt program for
UK junior doctors. World J Surg. 2012;36(5):956-8. doi:10.1007/s00268-012-1499-y.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/836867/psn-pdf
April 06, 2022 - Safer Dx Checklist: 10 High-Priority Practices for
Diagnostic Excellence.
April 6, 2022
Houston TX; Baylor College of Medicine: 2022.
https://psnet.ahrq.gov/issue/safer-dx-checklist-10-high-priority-practices-diagnostic-excellence
Assessment can identify the current state of a process or program to reveal ar…
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psnet.ahrq.gov/node/44610/psn-pdf
May 03, 2017 - International Prize in Resilient Health Care.
May 3, 2017
The Australian Institute of Health Innovation.
https://psnet.ahrq.gov/issue/international-prize-resilient-health-care
Innovations in patient safety can drive improvement efforts. This award program seeks to recognize
feasible and widely implementable strate…
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psnet.ahrq.gov/node/38395/psn-pdf
January 02, 2017 - Reducing medication errors and improving systems
reliability using an electronic medication reconciliation
system.
January 2, 2017
Agrawal A, Wu WY. Reducing Medication Errors and Improving Systems Reliability Using an Electronic
Medication Reconciliation System. The Joint Commission Journal on Quality and Patient…
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psnet.ahrq.gov/node/37119/psn-pdf
March 24, 2011 - Patient safety: helping medical students understand error
in healthcare.
March 24, 2011
Patey R, Flin R, Cuthbertson BH, et al. Patient safety: helping medical students understand error in
healthcare. Qual Saf Health Care. 2007;16(4):256-9.
https://psnet.ahrq.gov/issue/patient-safety-helping-medical-students-under…
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psnet.ahrq.gov/node/36387/psn-pdf
July 14, 2010 - Effectiveness of a community collaborative for
eliminating the use of high-risk abbreviations written by
physicians.
July 14, 2010
Leonhardt KK, Botticelli J. Effectiveness of a Community Collaborative for Eliminating the Use of High-risk
Abbreviations Written by Physicians. J Patient Saf. 2008;2(3). doi:10.1097/0…
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psnet.ahrq.gov/node/43354/psn-pdf
July 16, 2014 - Weaving a healthcare tapestry of safety and
communication.
July 16, 2014
Hay J, Collin S, Koruth S. Weaving a healthcare tapestry of safety and communication. Nurs Manage.
2014;45(7):40-6. doi:10.1097/01.NUMA.0000451035.84587.7d.
https://psnet.ahrq.gov/issue/weaving-healthcare-tapestry-safety-and-communication
Th…
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psnet.ahrq.gov/node/47354/psn-pdf
November 21, 2018 - Improving Diagnosis in Medicine Change Package.
November 21, 2018
Chicago, IL: Health Research & Educational Trust; 2018.
https://psnet.ahrq.gov/issue/improving-diagnosis-medicine-change-package
Proactive identification of conditions that degrade the diagnostic process can drive improvement. This
toolkit provides …
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psnet.ahrq.gov/node/73451/psn-pdf
June 30, 2021 - National Patient Safety Syllabus.
June 30, 2021
Spurgeon P, Cross S. London, UK; Academy of Medical Royal Colleges: May 2021.
https://psnet.ahrq.gov/issue/national-patient-safety-syllabus
Amending curricula to incorporate the increasing scholarship related to patient safety improvement is a
challenge. This st…
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psnet.ahrq.gov/node/41312/psn-pdf
April 18, 2012 - Functional safety of health information technology.
April 18, 2012
Chadwick L, Fallon EF, van der Putten WJ, et al. Functional safety of health information technology. Health
Informatics J. 2012;18(1):36-49. doi:10.1177/1460458211432587.
https://psnet.ahrq.gov/issue/functional-safety-health-information-technology
…
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psnet.ahrq.gov/node/46055/psn-pdf
July 26, 2017 - Bridging the gap between work-as-imagined and work-as-
done.
July 26, 2017
Deutsch ES. PA-PSRS Patient Saf Advis. June 2017;14:80-83.
https://psnet.ahrq.gov/issue/bridging-gap-between-work-imagined-and-work-done
Understanding what is possible in the context of frontline practice is key when designing enhancements …
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psnet.ahrq.gov/node/36746/psn-pdf
August 02, 2011 - Patient safety event reporting in critical care: a study of
three intensive care units.
August 2, 2011
Harris CB, Krauss MJ, Coopersmith CM, et al. Patient safety event reporting in critical care: a study of
three intensive care units. Crit Care Med. 2007;35(4):1068-76.
https://psnet.ahrq.gov/issue/patient-safety-…
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psnet.ahrq.gov/node/73123/psn-pdf
April 01, 2020 - Digital Healthcare Research.
April 1, 2020
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/digital-healthcare-research
An understanding of the impact that digital tools can have on clinical decision making, patient self-care, and
health system improvement is still emerging. This website hi…
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psnet.ahrq.gov/training-catalog/capture-falls-collaboration-and-proactive-teamwork-used-reduce-falls-program
August 11, 2025 - CAPTURE Falls (Collaboration And Proactive Teamwork Used to Reduce Falls) Program
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University of Nebraska College of…
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psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
December 23, 2020 - Life-Threatening Infant Overdose of Sodium Chloride
Citation Text:
Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
August 14, 2024 - Subsequently, the patient suffered multiple falls despite the nursing staff implementing “fall precautions
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psnet.ahrq.gov/node/33608/psn-pdf
February 01, 2024 - Maternal Safety
January 31, 2024
Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/maternal-safety
Originally published in 2018 by researchers at the University of California, San Francisco. Updated in
February 2024 by Marla Shauer, PhD(c), MSN, CNM, Amy Nichols,…
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psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change-it-and-how-it-changes-safety
March 01, 2017 - Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety
Sara J. Singer, MBA, PhD | March 1, 2017
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Citation Text:
Singer SJ. Our Maturing Understanding of Safety C…