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psnet.ahrq.gov/node/74143/psn-pdf
December 01, 2021 - Confronting Racism in Health Care: Moving from
Proclamations to New Practices.
December 1, 2021
Hostetter M, Klein S. New York, NY: Commonwealth Fund; October 18, 2021
https://psnet.ahrq.gov/issue/confronting-racism-health-care-moving-proclamations-new-practices
Structural racism affects the safety and equit…
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psnet.ahrq.gov/node/848384/psn-pdf
May 03, 2023 - Roadmap to Health Care Safety for Massachusetts.
May 3, 2023
Massachusetts Healthcare Safety and Quality Consortium. Boston, MA: Betsy Lehman Center for Patient
Safety; April 2023.
https://psnet.ahrq.gov/issue/roadmap-health-care-safety-massachusetts
Collective engagement and focus are required to attain large sys…
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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/34701/psn-pdf
January 04, 2017 - Making the business case for patient safety.
January 4, 2017
Weeks WB, Bagian JP. Making the business case for patient safety. Jt Comm J Qual Saf. 2003;29(1):51-4,
1.
https://psnet.ahrq.gov/issue/making-business-case-patient-safety
While the costs of medical error to patients are well appreciated, the direct costs…
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psnet.ahrq.gov/node/34659/psn-pdf
April 07, 2010 - Leading change: why transformation efforts fail.
April 7, 2010
Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail
Kotter, a professor at Harvard Business School, outlines the eight stages of a successful change process,
as well a…
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psnet.ahrq.gov/node/44053/psn-pdf
November 16, 2015 - ANA CAUTI Prevention Tool.
November 16, 2015
Silver Spring, MD: American Nurses Association; 2015.
https://psnet.ahrq.gov/issue/ana-cauti-prevention-tool
Nurses play an important role in reducing catheter–associated urinary tract infections (CAUTIs). This
toolkit, developed as a Partnership for Patients strategy, …
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psnet.ahrq.gov/node/836999/psn-pdf
April 27, 2022 - Toolkit for Preventing CLABSI and CAUTI in ICUs.
April 27, 2022
Rockville, MD: Agency for Healthcare Research and Quality; April 2022.
https://psnet.ahrq.gov/issue/toolkit-preventing-clabsi-and-cauti-icus
Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this
cu…
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psnet.ahrq.gov/node/42000/psn-pdf
March 06, 2013 - Measurement and training of TeamSTEPPS dimensions
using the Medical Team Performance Assessment Tool.
March 6, 2013
Lineberry M, Bryan E, Brush T, et al. Measurement and training of TeamSTEPPS dimensions using the
Medical Team Performance Assessment Tool. Jt Comm J Qual Patient Saf. 2013;39(2):89-95.
https://psnet…
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psnet.ahrq.gov/node/73200/psn-pdf
April 28, 2021 - Association in 2001), recurrent admissions related
https://psnet.ahrq.gov//#5
https://psnet.ahrq.gov/issue/implementing-closing-loop-safe-practices-diagnostic-results
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psnet.ahrq.gov/node/49861/psn-pdf
May 01, 2019 - use of standardized handoff tools has been shown to decrease adverse events
and improve safety.(19) Implementing
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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - Implementing a red syringe color change for all Succinylcholine drug administration in Australia has
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psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
August 01, 2005 - participating in the Institute for Healthcare Improvement's (IHI) campaign to save 100,000 lives a year by implementing
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psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
February 26, 2025 - Within a year of analyzing cases and implementing corrective actions using this method, there was a huge
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psnet.ahrq.gov/web-mm/volume-too-low-and-out
July 01, 2017 - All providers of care to children should be aware of these considerations and aided in implementing and
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psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - Situational Awareness and Patient Safety
April 1, 2016
Implementing
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psnet.ahrq.gov/node/49777/psn-pdf
December 01, 2016 - Suicide is one example of a comprehensive systems
approach to mitigating suicide risk and involves implementing
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psnet.ahrq.gov/node/33702/psn-pdf
November 01, 2010 - program and with the incentives for electronic
health record adoption, more and more hospitals will be implementing
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psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
March 15, 2023 - During a Time of Crisis
March 15, 2023
Developing strategic recommendations for implementing
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - Partnership as a pathway to diagnostic excellence: the challenges and successes of implementing
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psnet.ahrq.gov/curated-library/nurse-wellbeing-and-patient-safety
August 30, 2023 - Increasingly, health care institutions are implementing programs designed to provide emotional support