-
psnet.ahrq.gov/issue/successful-implementation-department-veterans-affairs-national-surgical-quality-improvement
March 28, 2012 - Study
Successful implementation of the Department of Veterans Affairs' National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery study.
Citation Text:
Khuri SF, Henderson WG, Daley J, et al. Successful implementation of the Department of Veteran…
-
psnet.ahrq.gov/issue/data-driven-quality-improvement-culture-change-and-high-reliability-journey-special-hospital
March 24, 2021 - Commentary
Data-driven quality improvement, culture change, and the high reliability journey at a special hospital for people with medically complex developmental disabilities.
Citation Text:
Barba V, Foreman K, Robey K. Data-driven quality improvement, culture change, and the high relia…
-
psnet.ahrq.gov/issue/improving-employee-voice-about-transgressive-or-disruptive-behavior-case-study
June 16, 2021 - Study
Improving employee voice about transgressive or disruptive behavior: a case study.
Citation Text:
Dixon-Woods M, Campbell A, Martin G, et al. Improving Employee Voice About Transgressive or Disruptive Behavior: A Case Study. Acad Med. 2019;94(4):579-585. doi:10.1097/ACM.00000000000…
-
psnet.ahrq.gov/issue/application-theoretical-framework-behavior-change-hospital-workers-real-time-explanations
October 12, 2022 - Study
Application of a theoretical framework for behavior change to hospital workers' real-time explanations for noncompliance with hand hygiene guidelines.
Citation Text:
Fuller C, Besser S, Savage J, et al. Application of a theoretical framework for behavior change to hospital worker…
-
psnet.ahrq.gov/issue/delivering-promise-cler-patient-safety-rotation-aligns-resident-education-hospital-processes
March 25, 2017 - Study
Delivering on the promise of CLER: a patient safety rotation that aligns resident education with hospital processes.
Citation Text:
Patel E, Muthusamy V, Young JQ. Delivering on the Promise of CLER: A Patient Safety Rotation That Aligns Resident Education With Hospital Processes. A…
-
psnet.ahrq.gov/issue/identifying-and-analyzing-diagnostic-paths-new-approach-studying-diagnostic-practices
July 17, 2019 - Commentary
Identifying and analyzing diagnostic paths: a new approach for studying diagnostic practices.
Citation Text:
Rao G, Epner P, Bauer V, et al. Identifying and analyzing diagnostic paths: a new approach for studying diagnostic practices. Diagnosis (Berl). 2017;4(2):67-72. doi:10.…
-
psnet.ahrq.gov/issue/novel-process-introducing-new-intraoperative-program-multidisciplinary-paradigm-mitigating
January 02, 2017 - Study
A novel process for introducing a new intraoperative program: a multidisciplinary paradigm for mitigating hazards and improving patient safety.
Citation Text:
Rodriguez-Paz JM, Mark L, Herzer KR, et al. A novel process for introducing a new intraoperative program: a multidiscipli…
-
psnet.ahrq.gov/issue/association-between-hospital-reported-leapfrog-safe-practices-scores-and-inpatient-mortality
January 23, 2020 - Study
Association between hospital-reported Leapfrog Safe Practices scores and inpatient mortality.
Citation Text:
Werner RM, McNutt RA. A New Strategy to Improve Quality. JAMA. 2009;301(13). doi:10.1001/jama.2009.423.
Copy Citation
Format:
DOI Google Scholar BibTeX EndNo…
-
psnet.ahrq.gov/issue/real-time-patient-safety-audits-improving-safety-every-day
April 14, 2021 - Study
Real time patient safety audits: improving safety every day.
Citation Text:
Ursprung R. Real time patient safety audits: improving safety every day. Qual Saf Health Care. 2005;14(4):284-289. doi:10.1136/qshc.2004.012542.
Copy Citation
Format:
DOI Google Scholar BibT…
-
psnet.ahrq.gov/issue/toward-improving-patient-safety-through-voluntary-peer-peer-assessment
August 25, 2015 - Commentary
Toward improving patient safety through voluntary peer-to-peer assessment.
Citation Text:
Hudson DW, Holzmueller CG, Pronovost P, et al. Toward improving patient safety through voluntary peer-to-peer assessment. Am J Med Qual. 2012;27(3):201-9. doi:10.1177/1062860611421981. …
-
psnet.ahrq.gov/issue/american-college-surgeons-closed-claims-study-new-insights-improving-care
March 02, 2011 - Study
The American College of Surgeons' closed claims study: new insights for improving care.
Citation Text:
Griffen FD, Stephens LS, Alexander JB, et al. The American College of Surgeons’ Closed Claims Study: New Insights for Improving Care. J Am Coll Surg. 2007;204(4). doi:10.1016/j.…
-
psnet.ahrq.gov/node/50844/psn-pdf
January 29, 2020 - Improving Patient Safety and Team Communication
through Daily Huddles
January 29, 2020
Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet].
2020.
https://psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
Background
Communicat…
-
psnet.ahrq.gov/node/33606/psn-pdf
December 15, 2024 - Opioid Safety
December 15, 2024
Opioid Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/opioid-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Bac…
-
psnet.ahrq.gov/node/836864/psn-pdf
April 06, 2022 - Improving the specificity of drug-drug interaction alerts:
can it be done?
April 6, 2022
Reese T, Wright A, Liu S, et al. Improving the specificity of drug-drug interaction alerts: Can it be done? Am
J Health Syst Pharm. 2022;79(13):1086-1095. doi:10.1093/ajhp/zxac045.
https://psnet.ahrq.gov/issue/improving-specif…
-
psnet.ahrq.gov/node/50672/psn-pdf
January 01, 2020 - Deprescribing as a clinical improvement focus.
November 20, 2019
Dharmarajan TS, Choi H, Hossain N, et al. Deprescribing as a Clinical Improvement Focus. J Am Med Dir
Assoc. 2020;21(3):355-360. doi:10.1016/j.jamda.2019.08.031.
https://psnet.ahrq.gov/issue/deprescribing-clinical-improvement-focus
Polypharmacy is a …
-
psnet.ahrq.gov/node/34748/psn-pdf
March 07, 2005 - Reducing Adverse Drug Events.
March 7, 2005
Leape LL, Kabcenell A, Berwick DM et al. Boston, MA: Institute for Healthcare Improvement; 1998.
https://psnet.ahrq.gov/issue/reducing-adverse-drug-events
This application-oriented book provides the results of the Institute for Healthcare Improvement (IHI)
Breakthrough S…
-
psnet.ahrq.gov/node/845352/psn-pdf
September 06, 2023 - Understanding and Improving Diagnostic Safety in
Ambulatory Care.
September 6, 2023
Rockville, MD: Agency for Healthcare Quality and Research; August 22, 2023.
https://psnet.ahrq.gov/issue/understanding-and-improving-diagnostic-safety-ambulatory-care
The articulation of diagnostic error in the ambulatory setting i…
-
psnet.ahrq.gov/node/38055/psn-pdf
January 12, 2009 - Improving patient safety: patient-focused, high-reliability
team training.
January 12, 2009
McKeon LM, Cunningham PD, Oswaks JSD. Improving patient safety: patient-focused, high-reliability team
training. J Nurs Care Qual. 2009;24(1):76-82. doi:10.1097/NCQ.0b013e31818f5595.
https://psnet.ahrq.gov/issue/improving-p…
-
psnet.ahrq.gov/node/838639/psn-pdf
October 19, 2022 - Calibrate Dx: A Resource to Improve Diagnostic
Decisions.
October 19, 2022
Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication no. 22(23)-
0047-2-EF.
https://psnet.ahrq.gov/issue/calibrate-dx-resource-improve-diagnostic-decisions
Delayed, wrong, and missed diagnoses are commo…
-
psnet.ahrq.gov/node/42774/psn-pdf
May 28, 2015 - Patient safety in plastic surgery: identifying areas for
quality improvement efforts.
May 28, 2015
Hernandez-Boussard T, McDonald KM, Rhoads KF, et al. Patient safety in plastic surgery: identifying areas
for quality improvement efforts. Ann Plast Surg. 2015;74(5):597-602.
doi:10.1097/SAP.0b013e318297791e.
https:…