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  1. Psn-Pdf (pdf file)

    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 …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43022/psn-pdf
    May 29, 2014 - Using simulation to improve root cause analysis of adverse surgical outcomes. May 29, 2014 Slakey DP, Simms ER, Rennie K, et al. Using simulation to improve root cause analysis of adverse surgical outcomes. Int J Qual Health Care. 2014;26(2):144-50. doi:10.1093/intqhc/mzu011. https://psnet.ahrq.gov/issue/using-sim…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46243/psn-pdf
    June 05, 2019 - AHRQ Safety Program for Improving Surgical Care and Recovery. June 5, 2019 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/ahrq-safety-program-improving-surgical-care-and-recovery Patients are vulnerable to harm after surgery. This program used methods from the Comprehensive Unit- based S…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38363/psn-pdf
    February 23, 2009 - Critical care checklists, the Keystone Project, and the Office for Human Research Protections: a case for streamlining the approval process in quality-improvement research. February 23, 2009 Savel RH, Goldstein EB, Gropper MA. Critical care checklists, the Keystone Project, and the Office for Human Research Prote…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
    April 26, 2023 - In Conversation With… Mark Chassin, MD, MPP, MPH April 1, 2017  Citation Text: In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Cit…
  9. psnet.ahrq.gov/perspective/communication-during-transitions-care
    July 10, 2024 - Annual Perspective Communication During Transitions of Care Ayse P. Gurses; Sarah Mossburg; Zoe Sousane | March 27, 2024  View more articles from the same authors. Citation Text: Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PS…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50785/psn-pdf
    January 08, 2020 - Moving Measurement into Action: Global Principles for Measuring Patient Safety. January 8, 2020 IHI Lucian Leape Institute. Boston, MA: Institute for Healthcare Improvement, Salzburg Global Seminar; December 2019. https://psnet.ahrq.gov/issue/moving-measurement-action-global-principles-measuring-patient-safety Me…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837695/psn-pdf
    July 20, 2022 - Narrowing the mindware gap in medicine. July 20, 2022 Croskerry P. Narrowing the mindware gap in medicine. Diagnosis (Berl). 2022;9(2):176-183. doi:10.1515/dx-2020-0128. https://psnet.ahrq.gov/issue/narrowing-mindware-gap-medicine In dual process thinking, Type 1 decisions are made rapidly, but can result in diagn…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44807/psn-pdf
    September 29, 2017 - Legal and policy interventions to improve patient safety. September 29, 2017 Kachalia A, Mello MM, Nallamothu BK, et al. Legal and Policy Interventions to Improve Patient Safety. Circulation. 2016;133(7):661-71. doi:10.1161/CIRCULATIONAHA.115.015880. https://psnet.ahrq.gov/issue/legal-and-policy-interventions-impro…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854625/psn-pdf
    January 01, 2024 - Remote patient monitoring improves patient falls and reduces harm. October 18, 2023 Zimbro KS, Bridges C, Bunn S, et al. Remote patient monitoring improves patient falls and reduces harm. J Nurs Care Qual. 2024;39(3):212-219. doi:10.1097/ncq.0000000000000749. https://psnet.ahrq.gov/issue/remote-patient-monitoring-…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44640/psn-pdf
    February 20, 2016 - The problem with Plan-Do-Study-Act cycles. February 20, 2016 Reed JE, Card AJ. The problem with Plan-Do-Study-Act cycles. BMJ Qual Saf. 2016;25(3):147-52. doi:10.1136/bmjqs-2015-005076. https://psnet.ahrq.gov/issue/problem-plan-do-study-act-cycles Rapid-cycle improvement methods have been embraced as an approach t…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74858/psn-pdf
    February 23, 2022 - Improving responses to safety incidents: we need to talk about justice. February 23, 2022 Cribb A, O'Hara JK, Waring J. Improving responses to safety incidents: we need to talk about justice. BMJ Qual Saf. 2022;31(4):327-330. doi:10.1136/bmjqs-2021-014333. https://psnet.ahrq.gov/issue/improving-responses-safety-in…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44781/psn-pdf
    January 13, 2016 - Improving Pediatric Surgery Quality and Outcomes in the 21st Century. January 13, 2016 Heiss K, ed. Semin Pediatr Surg. 2015;24:265-326. https://psnet.ahrq.gov/issue/improving-pediatric-surgery-quality-and-outcomes-21st-century Articles in this special issue introduce quality improvement principles, such as system…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849137/psn-pdf
    May 17, 2023 - Medical errors kill thousands of people each year. But are hospitals getting any safer? May 17, 2023 Weintraub K. USA Today. May 3, 2023. https://psnet.ahrq.gov/issue/medical-errors-kill-thousands-people-each-year-are-hospitals-getting-any-safer The semi-annual Leapfrog Hospital Safety Grades are recognized across…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47662/psn-pdf
    February 21, 2024 - Lucian Leape Patient Safety Fellowship Award. February 21, 2024 International Society for Quality in Health Care https://psnet.ahrq.gov/issue/lucian-leape-patient-safety-fellowship-award Inspired by the work and leadership of Dr. Lucian Leape, this award is a mentoring program to develop physicians and leaders see…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60020/psn-pdf
    March 04, 2020 - The eNOTSS platform for surgeons’ nontechnical skills performance improvement. March 4, 2020 Pradarelli JC, Yule S, Smink DS. The eNOTSS Platform for Surgeons’ Nontechnical Skills Performance Improvement. JAMA Surg. 2020;155(5):438-439. doi:10.1001/jamasurg.2019.5880. https://psnet.ahrq.gov/issue/enotss-platform-s…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50808/psn-pdf
    January 15, 2020 - Health Services Research Priorities for Improving Diagnostic Safety and Quality. Special Emphasis Notice (SEN). January 15, 2020 Rockville, MD: Agency for Healthcare Research and Quality. December 27, 2019. Publication No. NOT- HS-20-004. https://psnet.ahrq.gov/issue/health-services-research-priorities-improving-…

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