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psnet.ahrq.gov/node/33590/psn-pdf
September 15, 2024 - Leadership Role in Improving Safety
September 15, 2024
Leadership Role in Improving Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/leadership-role-improving-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and p…
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psnet.ahrq.gov/node/867676/psn-pdf
February 26, 2025 - Responding to Patient Safety Events
February 26, 2025
Shaikh U. Responding to Patient Safety Events. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/responding-patient-safety-events
Background
Patient safety events that occur in health care facilities require prompt action to ensure that further harm is
mit…
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psnet.ahrq.gov/node/48044/psn-pdf
June 12, 2019 - What has an Airbus A380 captain got to do with OMFS?
Lessons from aviation to improve patient safety.
June 12, 2019
Davidson M, Brennan PA. Leading article: What has an Airbus A380 Captain got to do with OMFS?
Lessons from aviation to improve patient safety. Br J Oral Maxillofac Surg. 2019;57(5):407-411.
doi:10.10…
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psnet.ahrq.gov/node/847532/psn-pdf
April 12, 2023 - The impact of an intervention to improve intrapartum
maternal vital sign monitoring and reduce alarm fatigue.
April 12, 2023
Kern-Goldberger AR, Nicholls EM, Plastino N, et al. The impact of an intervention to improve intrapartum
maternal vital sign monitoring and reduce alarm fatigue. Am J Obstet Gynecol MFM. 2023…
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psnet.ahrq.gov/node/764390/psn-pdf
March 02, 2022 - Does root cause analysis improve patient safety? A
systematic review at the Department of Veterans Affairs.
March 2, 2022
Shah F, Falconer EA, Cimiotti JP. Does root cause analysis improve patient safety? A systematic review at
the Department of Veterans Affairs. Qual Manag Health Care. 2022;31(4):231-241.
doi:10.…
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psnet.ahrq.gov/node/44513/psn-pdf
September 23, 2015 - Improving Diagnosis in Health Care.
September 23, 2015
Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine.
Washington, DC: National Academies Press; 2015. ISBN: 9780309377690.
https://psnet.ahrq.gov/issue/improving-diagnosis-health-care
The National Academy of Me…
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psnet.ahrq.gov/node/867133/psn-pdf
November 13, 2024 - Designing an intervention to improve medication safety
for nursing home residents based on experiential
knowledge related to patient safety culture at the nursing
home front line: cocreative process study.
November 13, 2024
Juhl MH, Soerensen AL, Vardinghus-Nielsen H, et al. Designing an intervention to improve me…
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psnet.ahrq.gov/node/37856/psn-pdf
June 16, 2011 - Improving patient safety in intensive care units in
Michigan.
June 16, 2011
Pronovost P, Berenholtz SM, Goeschel CA, et al. Improving patient safety in intensive care units in
Michigan. J Crit Care. 2008;23(2):207-212. doi:10.1016/j.jcrc.2007.09.002.
https://psnet.ahrq.gov/issue/improving-patient-safety-intensive-…
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psnet.ahrq.gov/node/35813/psn-pdf
April 06, 2011 - Simulation based teamwork training for emergency
department staff: does it improve clinical team
performance when added to an existing didactic
teamwork curriculum?
April 6, 2011
Shapiro MJ, Morey JC, Small SD, et al. Simulation based teamwork training for emergency department
staff: does it improve clinical team…
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psnet.ahrq.gov/node/37927/psn-pdf
March 10, 2011 - A randomized trial of electronic clinical reminders to
improve medication laboratory monitoring.
March 10, 2011
Matheny ME, Sequist TD, Seger AC, et al. A randomized trial of electronic clinical reminders to improve
medication laboratory monitoring. J Am Med Inform Assoc. 2008;15(4):424-9. doi:10.1197/jamia.M2602.
…
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psnet.ahrq.gov/node/60580/psn-pdf
January 01, 2022 - Sustaining the gains: a 7-year follow-through of a
hospital-wide patient safety improvement project on
hospital-wide adverse event outcomes and patient safety
culture.
June 10, 2020
Sim MA, Ti LK, Mujumdar S, et al. Sustaining the gains: a 7-year follow-through of a hospital-wide patient
safety improvement projec…
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psnet.ahrq.gov/node/844550/psn-pdf
September 01, 2012 - The effect of a Lean quality improvement implementation
program on surgical pathology specimen accessioning
and gross preparation error frequency.
September 1, 2012
Smith ML, Wilkerson T, Grzybicki DM, et al. The effect of a Lean quality improvement implementation
program on surgical pathology specimen accessionin…
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psnet.ahrq.gov/node/74098/psn-pdf
January 01, 2023 - Reducing failure to rescue rates in a paediatric in-patient
setting: a 9-year quality improvement study.
November 24, 2021
McHale S, Marufu TC, Manning JC, et al. Reducing failure to rescue rates in a paediatric in?patient setting:
a 9?year quality improvement study. Nurs Crit Care. 2023;28(1):72-79. doi:10.1111/ni…
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psnet.ahrq.gov/node/866745/psn-pdf
September 18, 2024 - State of the Science and Future Directions to Improve
Diagnostic Safety in Older Adults.
September 18, 2024
Tran AK, Syed Q, Bierman AS, et al. State Of The Science And Future Directions To Improve Diagnostic
Safety In Older Adults. Rockville, MD: Agency for Healthcare Research and Quality; September 2024.
AHRQ Pu…
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psnet.ahrq.gov/node/60540/psn-pdf
November 01, 2016 - Quality improvement initiatives lead to reduction in
nulliparous term singleton vertex cesarean delivery rate.
November 1, 2016
Vadnais MA, Hacker MR, Shah NT, et al. Quality improvement initiatives lead to reduction in nulliparous
term singleton vertex cesarean delivery rate. Jt Comm J Qual Patient Saf. 2016;43(2)…
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psnet.ahrq.gov/node/36902/psn-pdf
June 09, 2010 - Patient handover from surgery to intensive care: using
Formula 1 pit-stop and aviation models to improve safety
and quality.
June 9, 2010
Catchpole K, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using
Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr …
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psnet.ahrq.gov/node/60612/psn-pdf
January 01, 2021 - COVID-19: patient safety and quality improvement skills
to deploy during the surge.
June 24, 2020
Staines A, Amalberti R, Berwick DM, et al. COVID-19: patient safety and quality improvement skills to
deploy during the surge. Int J Qual Health Care. 2021;33(1):mzaa050. doi:10.1093/intqhc/mzaa050.
https://psnet.ahrq…
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psnet.ahrq.gov/node/843329/psn-pdf
February 01, 2023 - Improving administration and documentation of enteral
nutrition support therapy in a Veteran Affairs health care
system: use of medication administration record and bar
code scanning technology.
February 1, 2023
Chew MM, Rivas S, Chesser M, et al. Improving administration and documentation of enteral nutrition
su…
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psnet.ahrq.gov/node/40364/psn-pdf
July 01, 2011 - Utilising improvement science methods to optimise
medication reconciliation.
April 13, 2011
White CM, Schoettker PJ, Conway PH, et al. Utilising improvement science methods to optimise
medication reconciliation. BMJ Qual Saf. 2011;20(4):372-80. doi:10.1136/bmjqs.2010.047845.
https://psnet.ahrq.gov/issue/utilising-…
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psnet.ahrq.gov/node/60027/psn-pdf
January 01, 2021 - Data-driven quality improvement, culture change, and the
high reliability journey at a special hospital for people
with medically complex developmental disabilities.
March 11, 2020
Barba V, Foreman K, Robey K. Data-driven quality improvement, culture change, and the high reliability
journey at a special hospital f…