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psnet.ahrq.gov/node/37413/psn-pdf
November 14, 2011 - Patient Safety Tools: Improving Safety at the Point of
Care.
November 14, 2011
https://psnet.ahrq.gov/issue/patient-safety-tools-improving-safety-point-care-0
Produced in conjunction with its Partnerships in Implementing Patient Safety (PIPS) grant program,
AHRQ has released 17 freely available toolkits to help ho…
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psnet.ahrq.gov/node/45226/psn-pdf
January 04, 2017 - AHRQ Research Summit on Improving Diagnosis in
Health Care.
January 4, 2017
Rockville, MD; Agency for Healthcare Research and Quality: September 28, 2016.
https://psnet.ahrq.gov/issue/ahrq-research-summit-improving-diagnosis-health-care
Research is increasingly focusing on diagnostic errors and strategies to reduc…
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psnet.ahrq.gov/node/37788/psn-pdf
May 28, 2008 - Durable improvements in efficiency, safety, and
satisfaction in the operating room.
May 28, 2008
Heslin MJ, Doster BE, Daily SL, et al. Durable improvements in efficiency, safety, and satisfaction in the
operating room. J Am Coll Surg. 2008;206(5):1083-9; discussion 1089-90.
doi:10.1016/j.jamcollsurg.2008.02.006.
…
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psnet.ahrq.gov/node/43437/psn-pdf
August 13, 2014 - Diagnostic error: untapped potential for improving patient
safety?
August 13, 2014
Groszkruger D. Diagnostic error: untapped potential for improving patient safety? J Healthc Risk Manag.
2014;34(1):38-43. doi:10.1002/jhrm.21149.
https://psnet.ahrq.gov/issue/diagnostic-error-untapped-potential-improving-patient-saf…
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psnet.ahrq.gov/node/838221/psn-pdf
September 28, 2022 - In Conversation With... Freya Spielberg, MD, MPH
September 28, 2022
In Conversation With.. Freya Spielberg, MD, MPH. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
Editor’s Note: Freya Spielberg, MD, MPH, is the Founder and CEO of Urgent Wellness LLC, a social
enterp…
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psnet.ahrq.gov/issue/viewing-prevention-catheter-associated-urinary-tract-infection-system-using-systems
July 12, 2023 - Study
Viewing prevention of catheter-associated urinary tract infection as a system: using systems engineering and human factors engineering in a quality improvement project in an academic medical center.
Citation Text:
Rhee C, Phelps E, Meyer B, et al. Viewing Prevention of Catheter-Ass…
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psnet.ahrq.gov/node/34991/psn-pdf
June 22, 2009 - Use of failure mode and effects analysis in improving the
safety of i.v. drug administration.
June 22, 2009
Adachi W, Lodolce AE. Use of failure mode and effects analysis in improving the safety of i.v. drug
administration. Am J Health Syst Pharm. 2005;62(9):917-20.
https://psnet.ahrq.gov/issue/use-failure-mode-an…
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psnet.ahrq.gov/node/44529/psn-pdf
September 30, 2015 - Learning from no-fault treatment injury claims to improve
the safety of older patients.
September 30, 2015
Wallis KA. Learning from no-fault treatment injury claims to improve the safety of older patients. Ann Fam
Med. 2015;13(5):472-4. doi:10.1370/afm.1810.
https://psnet.ahrq.gov/issue/learning-no-fault-treatment…
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psnet.ahrq.gov/node/44760/psn-pdf
July 10, 2024 - Collaborative for Accountability and Improvement.
July 10, 2024
University of Washington.
https://psnet.ahrq.gov/issue/collaborative-accountability-and-improvement
Communication-and-resolution programs (CRPs) are a promising strategy to improve respectful and
effective discussions with patients and families after …
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psnet.ahrq.gov/node/45926/psn-pdf
May 17, 2017 - Toolkit To Improve Safety in Ambulatory Surgery Centers.
May 17, 2017
Rockville, MD: Agency for Healthcare Research and Quality; December 2014.
https://psnet.ahrq.gov/issue/toolkit-improve-safety-ambulatory-surgery-centers
Ambulatory surgery centers provide care to growing numbers of patients. This toolkit draws fr…
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psnet.ahrq.gov/node/41710/psn-pdf
November 08, 2012 - Improving teamwork on general medical units: when
teams do not work face-to-face.
November 8, 2012
McComb SA, Henneman EA, Hinchey KT, et al. Improving teamwork on general medical units: when teams
do not work face-to-face. Jt Comm J Qual Patient Saf. 2012;38(10):471-478.
https://psnet.ahrq.gov/issue/improving-tea…
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psnet.ahrq.gov/node/39257/psn-pdf
January 27, 2010 - Opportunities and Recommendations for State–Federal
Coordination to Improve Health System Performance: A
Focus on Patient Safety.
January 27, 2010
Buxbaum J. Portland, ME: National Academy for State Health Policy; January 2010.
https://psnet.ahrq.gov/issue/opportunities-and-recommendations-state-federal-coordinati…
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psnet.ahrq.gov/node/60627/psn-pdf
June 24, 2020 - Second opinions improve healthcare outcomes and
reduce costs.
June 24, 2020
Hébert AR. Second opinions improve healthcare outcomes and reduce costs. Employee Benefit News.
2020;June 8.
https://psnet.ahrq.gov/issue/second-opinions-improve-healthcare-outcomes-and-reduce-costs
Second opinions are a strategy for redu…
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psnet.ahrq.gov/node/36117/psn-pdf
July 19, 2006 - A Safer Place for Patients: Learning to Improve Patient
Safety.
July 19, 2006
House of Commons Committee on Public Accounts. London: The Stationery Office Limited; June 2006.
https://psnet.ahrq.gov/issue/safer-place-patients-learning-improve-patient-safety-0
Using data from approximately 974,000 patient safety inc…
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psnet.ahrq.gov/node/37432/psn-pdf
November 29, 2009 - The Pennsylvania Learning Exchange: Helping States
Improve and Integrate Patient Safety
Initiatives—Summary Report.
November 29, 2009
Hanlon C; Rosenthal J. Portland, ME: National Academy for State Health Policy; 2007.
https://psnet.ahrq.gov/issue/pennsylvania-learning-exchange-helping-states-improve-and-integrate…
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psnet.ahrq.gov/node/851926/psn-pdf
August 02, 2023 - Improving Patient Safety Culture – A Practical Guide.
August 2, 2023
London, UK: NHS England; July 2023.
https://psnet.ahrq.gov/issue/improving-patient-safety-culture-practical-guide
A strong patient safety culture needs nurturing to serve as a foundation for launching and sustaining
improvements. This toolkit pro…
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psnet.ahrq.gov/node/39915/psn-pdf
December 18, 2014 - Improving the quality of discharge communication with
an educational intervention.
December 18, 2014
Key-Solle M, Paulk E, Bradford K, et al. Improving the quality of discharge communication with an
educational intervention. Pediatrics. 2010;126(4):734-9. doi:10.1542/peds.2010-0884.
https://psnet.ahrq.gov/issue/im…
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psnet.ahrq.gov/node/40999/psn-pdf
January 01, 2012 - Improving patient safety via automated laboratory-based
adverse event grading.
December 15, 2011
Niland JC, Stiller T, Neat J, et al. Improving patient safety via automated laboratory-based adverse event
grading. J Am Med Inform Assoc. 2012;19(1):111-5. doi:10.1136/amiajnl-2011-000513.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
January 01, 2022 - Spotlight
Spotlight
False Assumptions Result in a Missed
Pneumothorax after Bronchoscopy with
Transbronchial Biopsy
Source and Credits
• This presentation is based on the September 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by:…
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psnet.ahrq.gov/issue/creating-learning-health-system-improving-diagnostic-safety-pragmatic-insights-us-health-care
May 12, 2021 - Study
Creating a learning health system for improving diagnostic safety: pragmatic insights from US health care organizations.
Citation Text:
Giardina TD, Shahid U, Mushtaq U, et al. Creating a learning health system for improving diagnostic safety: pragmatic insights from US health care…