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psnet.ahrq.gov/issue/introducing-safety-score-audit-staff-member-and-patient-safety
April 16, 2014 - Commentary
Introducing the safety score audit for staff member and patient safety.
Citation Text:
Sinnott M, Eley R, Winch S. Introducing the safety score audit for staff member and patient safety. AORN J. 2014;100(1):91-5. doi:10.1016/j.aorn.2014.05.006.
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psnet.ahrq.gov/issue/critical-care-checklists-keystone-project-and-office-human-research-protections-case
May 04, 2014 - Commentary
Critical care checklists, the Keystone Project, and the Office for Human Research Protections: a case for streamlining the approval process in quality-improvement research.
Citation Text:
Savel RH, Goldstein EB, Gropper MA. Critical care checklists, the Keystone Project, an…
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psnet.ahrq.gov/issue/am-i-safe-here-improving-patients-perceptions-safety-hospitals
June 25, 2010 - Study
Am I safe here? Improving patients' perceptions of safety in hospitals.
Citation Text:
Wolosin RJ, Vercler L, Matthews JL. Am I safe here?: improving patients' perceptions of safety in hospitals. J Nurs Care Qual. 2006;21(1):30-40.
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psnet.ahrq.gov/issue/determinants-success-quality-improvement-collaboratives-what-does-literature-show
May 22, 2013 - Study
Determinants of success of quality improvement collaboratives: what does the literature show?
Citation Text:
Hulscher M, Schouten LMT, Grol R, et al. Determinants of success of quality improvement collaboratives: what does the literature show? BMJ Qual Saf. 2013;22(1):19-31. doi:…
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psnet.ahrq.gov/issue/quality-management-and-patient-safety-survey-results-102-hungarian-hospitals
September 16, 2015 - Study
Quality management and patient safety: survey results from 102 Hungarian hospitals.
Citation Text:
Makai P, Klazinga NS, Wagner C, et al. Quality management and patient safety: survey results from 102 Hungarian hospitals. Health Policy (New York). 2009;90(2-3):175-80. doi:10.1016/…
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psnet.ahrq.gov/issue/system-safety-approach-assessing-risks-sepsis-treatment-process
February 03, 2021 - Study
A system safety approach to assessing risks in the sepsis treatment process.
Citation Text:
Kaya GK. A system safety approach to assessing risks in the sepsis treatment process. Appl Ergon. 2021;94:103408. doi:10.1016/j.apergo.2021.103408.
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psnet.ahrq.gov/issue/residents-reflections-quality-improvement-temporal-stability-and-associations-preventability
September 20, 2011 - Study
Residents' reflections on quality improvement: temporal stability and associations with preventability of adverse patient events.
Citation Text:
Wittich CM, Reed DA, Drefahl MM, et al. Residents' reflections on quality improvement: temporal stability and associations with preventab…
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psnet.ahrq.gov/issue/customized-triggers-program-childrens-hospitals-experience-improving-trigger-usability
September 01, 2021 - Study
A customized triggers program: a children's hospital's experience in improving trigger usability.
Citation Text:
Reinhart RM, Safari-Ferra P, Badh R, et al. A customized triggers program: a children's hospital's experience in improving trigger usability. Pediatrics. 2023;151(2):e20…
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psnet.ahrq.gov/issue/hospital-commitments-address-diagnostic-errors-assessment-95-us-hospitals
September 18, 2024 - Study
Hospital commitments to address diagnostic errors: an assessment of 95 US hospitals.
Citation Text:
Campione Russo A, Tilly J‐L, Kaufman L, et al. Hospital commitments to address diagnostic errors: an assessment of 95 US hospitals. J Hosp Med. 2025;20(2):120-134. doi:10.1002/jhm.13…
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psnet.ahrq.gov/issue/improving-documentation-beta-blocker-quality-measure-through-anesthesia-information
June 23, 2009 - Study
Improving documentation of a beta-blocker quality measure through an anesthesia information management system and real-time notification of documentation errors.
Citation Text:
Nair BG, Peterson GN, Newman S-F, et al. Improving documentation of a beta-blocker quality measure throug…
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psnet.ahrq.gov/issue/lessons-learned-use-event-reporting-nurses-improve-patient-safety-and-quality
May 19, 2013 - Study
Lessons learned: use of event reporting by nurses to improve patient safety and quality.
Citation Text:
Hession-Laband E, Mantell P. Lessons learned: use of event reporting by nurses to improve patient safety and quality. J Pediatr Nurs. 2011;26(2):149-55. doi:10.1016/j.pedn.2010…
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psnet.ahrq.gov/issue/adopting-system-models-multiple-incident-analysis-utility-and-usability
May 19, 2021 - Study
Adopting system models for multiple incident analysis: utility and usability.
Citation Text:
Wheway JL, Jun GT. Adopting systems models for multiple incident analysis: utility and usability. Int J Qual Health Care. 2021;33(4):mzab135. doi:10.1093/intqhc/mzab135.
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psnet.ahrq.gov/issue/adoption-order-entry-decision-support-chronic-care-physician-organizations
October 06, 2011 - Study
Adoption of order entry with decision support for chronic care by physician organizations.
Citation Text:
Simon JS, Rundall TG, Shortell SM. Adoption of order entry with decision support for chronic care by physician organizations. J Am Med Inform Assoc. 2007;14(4):432-9.
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psnet.ahrq.gov/issue/err-human-improving-diagnosis-health-care-risk-management-perspective
April 24, 2018 - Commentary
From To Err Is Human to Improving Diagnosis in Health Care: the risk management perspective.
Citation Text:
Bunting RF, Groszkruger DP. From To Err Is Human to Improving Diagnosis in Health Care: The risk management perspective. J Healthc Risk Manag. 2016;35(3):10-23. doi:10.1…
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psnet.ahrq.gov/node/45227/psn-pdf
January 21, 2017 - Implementing delivery room checklists and
communication standards in a multi-neonatal ICU quality
improvement collaborative.
January 21, 2017
Bennett SC, Finer N, Halamek LP, et al. Implementing Delivery Room Checklists and Communication
Standards in a Multi-Neonatal ICU Quality Improvement Collaborative. Jt Comm …
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psnet.ahrq.gov/node/43070/psn-pdf
August 20, 2014 - Reducing the rate of catheter-associated bloodstream
infections in a surgical intensive care unit using the
Institute for Healthcare Improvement Central Line Bundle.
August 20, 2014
Sacks GD, Diggs BS, Hadjizacharia P, et al. Reducing the rate of catheter-associated bloodstream
infections in a surgical intensive c…
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psnet.ahrq.gov/node/41701/psn-pdf
September 26, 2019 - The CUSP Method
September 26, 2019
The CUSP Method.
https://psnet.ahrq.gov/issue/cusp-method
The Comprehensive Unit-based Safety Program (CUSP), originally developed at Johns Hopkins Hospital
by Dr. Peter Pronovost and colleagues, has been instrumental in driving patient safety improvement in
several landmark pat…
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psnet.ahrq.gov/node/46749/psn-pdf
April 04, 2018 - Toolkit for Improving Perinatal Safety.
April 4, 2018
Rockville, MD: Agency for Healthcare Research and Quality. June 2017.
https://psnet.ahrq.gov/issue/toolkit-improving-perinatal-safety
Communication in labor and delivery units can be challenging. This AHRQ-funded program draws from
comprehensive unit-based safe…
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psnet.ahrq.gov/node/867094/psn-pdf
January 01, 2025 - Maximizing the ability of health IT and AI to improve
patient safety.
November 6, 2024
Singh H, Sittig DF, Classen DC. Maximizing the ability of health IT and AI to improve patient safety. JAMA
Intern Med. 2025;185(1):10-12. doi:10.1001/jamainternmed.2024.4343.
https://psnet.ahrq.gov/issue/maximizing-ability-healt…
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psnet.ahrq.gov/node/44294/psn-pdf
October 03, 2017 - You can't understand something you hide: transparency
as a path to improve patient safety.
October 3, 2017
Wachter R, Kaplan GS, Gandhi T, et al. Health Affairs Blog. June 22, 2015.
https://psnet.ahrq.gov/issue/you-cant-understand-something-you-hide-transparency-path-improve-patient-
safety
Transparency is recogn…