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psnet.ahrq.gov/node/38644/psn-pdf
May 20, 2009 - A quality initiative to decrease pathology specimen-
labeling errors using radiofrequency identification in a
high-volume endoscopy center.
May 20, 2009
Francis DL, Prabhakar S, Sanderson SO. A quality initiative to decrease pathology specimen-labeling
errors using radiofrequency identification in a high-volume en…
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psnet.ahrq.gov/node/38081/psn-pdf
September 24, 2008 - Making patients safer: nurses' responses to patient safety
alerts.
September 24, 2008
Lankshear A, Lowson K, Harden J, et al. Making patients safer: nurses’ responses to patient safety alerts. J
Adv Nurs. 2008;63(6). doi:10.1111/j.1365-2648.2008.04741.x.
https://psnet.ahrq.gov/issue/making-patients-safer-nurses-re…
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psnet.ahrq.gov/node/37415/psn-pdf
March 03, 2011 - Six year audit of cardiac arrests and medical emergency
team calls in an Australian outer metropolitan teaching
hospital.
March 3, 2011
Buist M, Harrison J, Abaloz E, et al. Six year audit of cardiac arrests and medical emergency team calls in
an Australian outer metropolitan teaching hospital. BMJ. 2007;335(7631)…
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psnet.ahrq.gov/node/43012/psn-pdf
January 07, 2016 - Uptake of quality-related event standards of practice by
community pharmacies.
January 7, 2016
Boyle TA, Bishop A, Overmars C, et al. Uptake of Quality-Related Event Standards of Practice by
Community Pharmacies. J Pharm Pract. 2015;28(5):442-9. doi:10.1177/0897190014522066.
https://psnet.ahrq.gov/issue/uptake-qua…
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psnet.ahrq.gov/node/50734/psn-pdf
December 11, 2019 - The evolution of patient safety procedures in an oral
surgery department
December 11, 2019
Graham C, Reid S, Lord TC, et al. The evolution of patient safety procedures in an oral surgery
department. Br Dent J. 2019;226(1):32-38. doi:10.1038/sj.bdj.2019.5.
https://psnet.ahrq.gov/issue/evolution-patient-safety-proce…
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psnet.ahrq.gov/node/34661/psn-pdf
March 07, 2005 - Teaching smart people how to learn.
March 7, 2005
Argyris C. Harvard Business Review. 1991:69(May-June):99+.
https://psnet.ahrq.gov/issue/teaching-smart-people-learn
Argyris, a Harvard Business School professor, theorizes that companies and organizations must learn in
order to continually improve and succeed, but …
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psnet.ahrq.gov/node/47142/psn-pdf
June 13, 2018 - Managing health IT risks: reflections and
recommendations.
June 13, 2018
Sujan M. Managing health IT risks: reflections and recommendations. J Innov Health Inform.
2018;25(1):952. doi:10.14236/jhi.v25i1.952.
https://psnet.ahrq.gov/issue/managing-health-it-risks-reflections-and-recommendations
Health information t…
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psnet.ahrq.gov/node/44733/psn-pdf
December 07, 2018 - Patient Safety in Ambulatory Settings: Technical Brief.
December 7, 2018
Evidence-based Practice Center. Rockville, MD: Agency for Healthcare Research and Quality; October 19,
2016.
https://psnet.ahrq.gov/issue/patient-safety-ambulatory-settings-technical-brief
The primary focus on patient safety research has been…
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psnet.ahrq.gov/node/44339/psn-pdf
July 29, 2015 - Rapid response systems: a systematic review and meta-
analysis.
July 29, 2015
Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit
Care. 2015;19(1). doi:10.1186/s13054-015-0973-y.
https://psnet.ahrq.gov/issue/rapid-response-systems-systematic-review-and-meta-analysis…
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psnet.ahrq.gov/node/37074/psn-pdf
October 03, 2011 - Perioperative patient safety: correct patient, correct
surgery, correct side--a multifaceted, cross-
organizational, interventional study.
October 3, 2011
Zohar E, Noga Y, Davidson E, et al. Perioperative patient safety: correct patient, correct surgery, correct
side--a multifaceted, cross-organizational, interven…
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psnet.ahrq.gov/node/39963/psn-pdf
December 06, 2010 - Critical incident monitoring in paediatric and adult critical
care: from reporting to improved patient outcomes?
December 6, 2010
Frey B, Schwappach DLB. Critical incident monitoring in paediatric and adult critical care: from reporting to
improved patient outcomes? Curr Opin Crit Care. 2010;16(6):649-53.
doi:10.1…
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psnet.ahrq.gov/node/40716/psn-pdf
March 22, 2017 - Promoting Safety and Quality Through Human Resource
Practices: Executive Summary.
March 22, 2017
McAlearney AS, Song P, Garman A, McHugh M, Caputo N. Rockville, MD: Agency for Healthcare
Research and Quality; August 2011. AHRQ Publication No. 11-0080-EF.
https://psnet.ahrq.gov/issue/promoting-safety-and-quality-th…
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psnet.ahrq.gov/node/48049/psn-pdf
May 29, 2019 - How one health system overcame resistance to a surgical
checklist.
May 29, 2019
Hilton K, Anderson A. Harv Bus Rev. May 20, 2019.
https://psnet.ahrq.gov/issue/how-one-health-system-overcame-resistance-surgical-checklist
This commentary describes how one health system worked to combat resistance to change associate…
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psnet.ahrq.gov/node/39943/psn-pdf
October 27, 2010 - Development of a training program for bar-code–assisted
medication administration in inpatient pharmacy.
October 27, 2010
Dartt LR, Schneider R. Development of a training program for bar-code-assisted medication administration
in inpatient pharmacy. Am J Health Syst Pharm. 2010;67(19):1592-4. doi:10.2146/ajhp090189…
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psnet.ahrq.gov/node/836789/psn-pdf
March 23, 2022 - COVID-19 Focused Inspection Initiative in Healthcare.
March 23, 2022
Occupational Safety and Health Administration. March 2, 2022.
https://psnet.ahrq.gov/issue/covid-19-focused-inspection-initiative-healthcare
The impact of nursing home inspections to ensure the quality and safety of the service environment is…
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psnet.ahrq.gov/node/45875/psn-pdf
May 10, 2017 - An improvement approach to integrate teaching teams in
the reporting of safety events.
May 10, 2017
Dunbar AE, Cupit M, Vath RJ, et al. An Improvement Approach to Integrate Teaching Teams in the
Reporting of Safety Events. Pediatrics. 2017;139(2). doi:10.1542/peds.2015-3807.
https://psnet.ahrq.gov/issue/improvemen…
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psnet.ahrq.gov/node/45496/psn-pdf
May 09, 2017 - The application of the Global Trigger Tool: a systematic
review.
May 9, 2017
Hibbert PD, Molloy CJ, Hooper TD, et al. The application of the Global Trigger Tool: a systematic review.
Int J Qual Health Care. 2016;28(6):640-649. doi:10.1093/intqhc/mzw115.
https://psnet.ahrq.gov/issue/application-global-trigger-tool-…
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psnet.ahrq.gov/node/40956/psn-pdf
January 01, 2016 - Michigan Health & Hospital Association Keystone
Obstetrics: a statewide collaborative for perinatal patient
safety in Michigan.
January 31, 2005
Simpson KR, Knox GE, Martin M, et al. Michigan Health & Hospital Association Keystone Obstetrics: A
Statewide Collaborative for Perinatal Patient Safety in Michigan. Jt C…
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psnet.ahrq.gov/node/867601/psn-pdf
January 22, 2025 - AI: promise or peril for patient safety.
January 22, 2025
Ullem BD, Hatlie MJ, Lounsbury O. AI: promise or peril for patient safety. J Patient Saf. 2025;21(1):34-37.
doi:10.1097/pts.0000000000001301.
https://psnet.ahrq.gov/issue/ai-promise-or-peril-patient-safety
Patients for Patient Safety US (PFPS-US) is a patie…
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psnet.ahrq.gov/node/60990/psn-pdf
October 07, 2020 - Tiered daily huddles: the power of teamwork in managing
large healthcare organisations.
October 7, 2020
Mihaljevic T. Tiered daily huddles: the power of teamwork in managing large healthcare organisations. BMJ
Qual Saf. 2020;29(12):1050-1052. doi:10.1136/bmjqs-2019-010575.
https://psnet.ahrq.gov/issue/tiered-daily…