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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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.…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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-…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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. …
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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)…
  16. Psn-Pdf (pdf file)

    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 …
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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-…
  20. Psn-Pdf (pdf file)

    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…

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