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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/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…
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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/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…
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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…
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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/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/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…
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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…
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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…
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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…
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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…
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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-…
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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…
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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…
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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…
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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…
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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…
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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…
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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-…