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psnet.ahrq.gov/issue/accountability-organisational-learning-and-risks-patient-safety-england-conflict-or
December 29, 2014 - Commentary
Accountability, organisational learning and risks to patient safety in England: conflict or compromise?
Citation Text:
Dodds A, Kodate N. Accountability, organisational learning and risks to patient safety in England: Conflict or compromise? Health Risk Soc. 2011;13(4):327-3…
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psnet.ahrq.gov/issue/next-phase-health-care-improvement-what-can-we-learn-social-movements
July 22, 2010 - Commentary
The next phase of health care improvement: what can we learn from social movements?
Citation Text:
Bate P, Robert G, Bevan H. The next phase of healthcare improvement: what can we learn from social movements? Qual Saf Health Care. 2004;13(1):62-6.
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psnet.ahrq.gov/issue/safety-obstetric-critical-care
August 29, 2011 - Review
Safety in obstetric critical care.
Citation Text:
Scholefield H. Safety in obstetric critical care. Best Pract Res Clin Obstet Gynaecol. 2008;22(5):965-82. doi:10.1016/j.bpobgyn.2008.06.009.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndN…
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - describing 7C’s, 9 9C’s, 10 or even 10C’s. 11 These models all identify functions that ultimately lead to improved … then developing targeted programs and interventions to address the needs in these areas can lead to improved
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psnet.ahrq.gov/curated-article-libraries
March 18, 2025 - Curated Libraries
Curated Libraries are groupings of PSNet content, curated by AHRQ and by other experts in the patient safety field.
Watch the video to learn more about how this new feature works and how it can be of benefit to you.
Latest PSNet…
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psnet.ahrq.gov/node/47233/psn-pdf
November 02, 2018 - The STEP-up programme: engaging all staff in patient
safety.
November 2, 2018
Hamblin-Brown DJ; Ingram J.
https://psnet.ahrq.gov/issue/step-programme-engaging-all-staff-patient-safety
A transparent and respectful hospital culture is the foundation for improving working conditions to reduce
preventable harm. This …
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psnet.ahrq.gov/node/865933/psn-pdf
May 22, 2024 - Utilizing pharmacogenomic testing can improve
medication safety and prevent harm.
May 22, 2024
ISMP Medication Safety Alert! Acute Care. 2024;29(9):1-4.
https://psnet.ahrq.gov/issue/utilizing-pharmacogenomic-testing-can-improve-medication-safety-and-
prevent-harm
Pharmacogenomics (PGx) refers to the impact of gen…
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psnet.ahrq.gov/node/867701/psn-pdf
August 01, 2017 - Toolkit To Improve Safety for Mechanically Ventilated
Patients.
August 1, 2017
Agency for Healthcare Research and Quality . Toolkit To Improve Safety for Mechanically Ventilated
Patients. August 2017.
https://psnet.ahrq.gov/issue/toolkit-improve-safety-mechanically-ventilated-patients
Patients requiring mechanica…
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psnet.ahrq.gov/node/837192/psn-pdf
May 25, 2022 - Declaration to Advance Patient Safety.
May 25, 2022
National Steering Committee for Patient Safety. Boston, MA: Institute for Healthcare Improvement; May
2022.
https://psnet.ahrq.gov/issue/declaration-advance-patient-safety
Leadership commitment is crucial to attaining sustainable improvement in patient safety. Th…
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psnet.ahrq.gov/node/73677/psn-pdf
September 08, 2021 - Toolkit for Engaging Patients to Improve Diagnostic
Safety.
September 8, 2021
Rockville, MD: Agency for Healthcare Research and Quality; August 2021. AHRQ Publication No.
21-0047-2-EF.
https://psnet.ahrq.gov/issue/toolkit-engaging-patients-improve-diagnostic-safety
Patient and family engagement is core to ef…
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psnet.ahrq.gov/node/44919/psn-pdf
March 30, 2016 - Rapid response teams improve outcomes—Part 1, Part 2,
and Part 3.
March 30, 2016
Intensive Care Med. 2016;42(4):591-601.
https://psnet.ahrq.gov/issue/rapid-response-teams-improve-outcomes-part-1-part-2-and-part-3
This three-part commentary presents differing views on whether rapid response teams (RRTs) improve
pa…
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psnet.ahrq.gov/node/74114/psn-pdf
November 24, 2021 - Addressing health care disparities by improving quality
and safety.
November 24, 2021
Sentinel Event Alert. Nov 10 2021;(64):1-7.
https://psnet.ahrq.gov/issue/addressing-health-care-disparities-improving-quality-and-safety
Health care disparities are emerging as a core patient safety issue. This alert introduces s…
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psnet.ahrq.gov/node/43372/psn-pdf
April 13, 2016 - A case for improving measurement of intraoperative
iatrogenic injuries.
April 13, 2016
Paruch JL, Ko CY, Bilimoria KY. A case for improving measurement of intraoperative iatrogenic injuries.
JAMA Surg. 2014;149(9):887-8. doi:10.1001/jamasurg.2013.5237.
https://psnet.ahrq.gov/issue/case-improving-measurement-intrao…
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psnet.ahrq.gov/node/45923/psn-pdf
April 19, 2017 - Huddles and debriefings: improving communication on
labor and delivery.
April 19, 2017
McQuaid-Hanson E, Pian-Smith MCM. Huddles and Debriefings: Improving Communication on Labor and
Delivery. Anesthesiol Clin. 2017;35(1):59-67. doi:10.1016/j.anclin.2016.09.006.
https://psnet.ahrq.gov/issue/huddles-and-debriefings…
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psnet.ahrq.gov/node/837593/psn-pdf
June 29, 2022 - Adverse event reporting priorities: an integrative review.
June 29, 2022
Falcone ML, Van Stee SK, Tokac U, et al. Adverse event reporting priorities: an integrative review. J
Patient Saf. 2022;18(4):e727-e740. doi:10.1097/pts.0000000000000945.
https://psnet.ahrq.gov/issue/adverse-event-reporting-priorities-integrat…
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psnet.ahrq.gov/node/42161/psn-pdf
April 03, 2013 - Positioning continuing education: boundaries and
intersections between the domains continuing education,
knowledge translation, patient safety and quality
improvement.
April 3, 2013
Kitto S, Bell M, Peller J, et al. Positioning continuing education: boundaries and intersections between the
domains continuing educ…
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psnet.ahrq.gov/node/34935/psn-pdf
June 23, 2009 - Improving patient care. The cognitive psychology of
missed diagnoses.
June 23, 2009
Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med.
2005;142(2):115-120.
https://psnet.ahrq.gov/issue/improving-patient-care-cognitive-psychology-missed-diagnoses
This case study de…
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psnet.ahrq.gov/node/46483/psn-pdf
October 04, 2017 - Fall Prevention in Hospitals Training Program.
October 4, 2017
Rockville, MD: Agency for Healthcare Research and Quality; 2017.
https://psnet.ahrq.gov/issue/fall-prevention-hospitals-training-program
Falls are a primary focus of quality and patient safety improvement efforts in hospitals. This training
program pro…
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psnet.ahrq.gov/node/45642/psn-pdf
November 09, 2016 - Rethinking medical ward quality.
November 9, 2016
Pannick S, Wachter R, Vincent CA, et al. Rethinking medical ward quality. BMJ. 2016;355:i5417.
doi:10.1136/bmj.i5417.
https://psnet.ahrq.gov/issue/rethinking-medical-ward-quality
Patient safety research and commentary often focus on specialized care processes rathe…
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psnet.ahrq.gov/node/43701/psn-pdf
July 03, 2016 - Blink or think: can further reflection improve initial
diagnostic impressions?
July 3, 2016
Hess BJ, Lipner RS, Thompson V, et al. Blink or think: can further reflection improve initial diagnostic
impressions? Acad Med. 2015;90(1):112-118. doi:10.1097/ACM.0000000000000550.
https://psnet.ahrq.gov/issue/blink-or-thi…