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psnet.ahrq.gov/node/46793/psn-pdf
February 28, 2018 - Patient safety movement: history and future directions.
February 28, 2018
Lark ME, Kirkpatrick K, Chung KC. Patient Safety Movement: History and Future Directions. J Hand Surg
Am. 2018;43(2). doi:10.1016/j.jhsa.2017.11.006.
https://psnet.ahrq.gov/issue/patient-safety-movement-history-and-future-directions
The pati…
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psnet.ahrq.gov/node/60868/psn-pdf
September 02, 2020 - Association between implementing comprehensive
learning collaborative strategies in a statewide
collaborative and changes in hospital safety culture.
September 2, 2020
Yuce TK, Yang AD, Johnson JK, et al. Association between implementing comprehensive learning
collaborative strategies in a statewide collaborative …
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psnet.ahrq.gov/node/47542/psn-pdf
January 16, 2019 - Utilizing a Systems and Design Thinking Approach for
Improving Well-Being Within Health Professional
Education and Health Care.
January 16, 2019
Kreitzer MJ, Carter K, Coffey DS, et al. NAM Perspectives. Washington, DC: National Academy of
Medicine; 2019.
https://psnet.ahrq.gov/issue/utilizing-systems-and-design-…
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psnet.ahrq.gov/node/45505/psn-pdf
July 01, 2017 - A model for the departmental quality management
infrastructure within an academic health system.
July 1, 2017
Mathews SC, Demski R, Hooper JE, et al. A Model for the Departmental Quality Management
Infrastructure Within an Academic Health System. Acad Med. 2017;92(5):608-613.
doi:10.1097/ACM.0000000000001380.
htt…
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psnet.ahrq.gov/node/46146/psn-pdf
June 07, 2017 - Increasing patient safety event reporting in an emergency
medicine residency.
June 7, 2017
Steen S, Jaeger C, Price L, et al. Increasing Patient Safety Event Reporting in an Emergency Medicine
Residency. BMJ Qual Improv Rep. 2017;6(1). doi:10.1136/bmjquality.u223876.w5716.
https://psnet.ahrq.gov/issue/increasing-p…
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psnet.ahrq.gov/node/849607/psn-pdf
May 31, 2023 - Use of technology to improve the adherence to surgical
safety checklists in the operating room.
May 31, 2023
Pati AB, Mishra TS, Chappity P, et al. Use of technology to improve the adherence to surgical safety
checklists in the operating room. Jt Comm J Qual Patient Saf. 2023;49(10):572-577.
doi:10.1016/j.jcjq.202…
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psnet.ahrq.gov/node/34848/psn-pdf
February 17, 2011 - Improving patient safety—five years after the IOM report.
February 17, 2011
Altman DE, Clancy CM, Blendon RJ. Improving Patient Safety — Five Years after the IOM Report. New
Engl J Med. 2004;351(20):2041-2043. doi:10.1056/nejmp048243.
https://psnet.ahrq.gov/issue/improving-patient-safety-five-years-after-iom-report…
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psnet.ahrq.gov/node/45283/psn-pdf
June 29, 2016 - Goals and Priorities for Health Care Organizations to
Improve Safety Using Health IT. Revised Report.
June 29, 2016
Graber ML, Bailey R, Johnston D. RTI International; Washington, DC: US Department of Health and
Human Services, Office of the National Coordinator for Health Information Technology; 2016.
https://psn…
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psnet.ahrq.gov/node/45218/psn-pdf
June 15, 2016 - Patient Safety and Quality Improvement Act of 2005--HHS
guidance regarding patient safety work product and
providers' external obligations.
June 15, 2016
Agency for Healthcare Research and Quality. Fed Regist. 2016;81(100);32655-32660.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005-hh…
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psnet.ahrq.gov/node/33799/psn-pdf
January 01, 2015 - Burnout Among Health Professionals and Its Effect on
Patient Safety
January 1, 2015
Lyndon A. Burnout Among Health Professionals and Its Effect on Patient Safety. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/burnout-among-health-professionals-and-its-effect-patient-safety
Annual Perspective 2015
Bur…
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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - Reconciling Doses
November 1, 2005
Federico F. Reconciling Doses. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/reconciling-doses
Case Objectives
List the steps involved in medication reconciliation.
Describe the role of each of the stakeholders in medication reconciliation.
Discuss how medication reconc…
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psnet.ahrq.gov/perspective/handoffs-and-transitions
February 01, 2007 - Annual Perspective
Handoffs and Transitions
Niraj Sehgal, MD, MPH | January 22, 2014
View more articles from the same authors.
Citation Text:
Sehgal NL. Handoffs and Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
January 01, 2021 - Spotlight
Spotlight
The Consequences of Miscommunication
Regarding a Possible Artifact
Source and Credits
• This presentation is based on the June 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Kriti Gwal, MD
o AHRQ WebM&M Edit…
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psnet.ahrq.gov/node/867345/psn-pdf
December 11, 2024 - Implementation of a high-reliability organization
framework in a large integrated health care system: a pre-
post quasi-experimental quality improvement project.
December 11, 2024
Sawyer AM, Thiyarajan S, Essen KE, et al. Implementation of a high-reliability organization framework in a
large integrated health care…
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psnet.ahrq.gov/node/854376/psn-pdf
October 11, 2023 - Community validation of an approach to detect delayed
diagnosis of appendicitis in big databases.
October 11, 2023
Michelson KA, McGarghan FLE, Waltzman ML, et al. Community validation of an approach to detect
delayed diagnosis of appendicitis in big databases. Hosp Pediatr. 2023;13(7):e170-e174.
doi:10.1542/hpeds…
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psnet.ahrq.gov/node/46546/psn-pdf
January 10, 2018 - Using an online quiz-based reinforcement system to
teach healthcare quality and patient safety and care
transitions at the University of California.
January 10, 2018
Shaikh U, Afsar-Manesh N, Amin AN, et al. Using an online quiz-based reinforcement system to teach
healthcare quality and patient safety and care tra…
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psnet.ahrq.gov/node/40806/psn-pdf
October 31, 2011 - How best to measure surgical quality? Comparison of the
Agency for Healthcare Research and Quality Patient
Safety Indicators (AHRQ-PSI) and the American College of
Surgeons National Surgical Quality Improvement Program
(ACS-NSQIP) postoperative adverse events at a single
institution.
October 31, 2011
Cima RR, La…
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psnet.ahrq.gov/node/36843/psn-pdf
January 05, 2017 - Improving medication reconciliation in the outpatient
setting.
January 5, 2017
Varkey P, Cunningham J, Bisping S. Improving medication reconciliation in the outpatient setting. Jt Comm
J Qual Patient Saf. 2007;33(5):286-92.
https://psnet.ahrq.gov/issue/improving-medication-reconciliation-outpatient-setting
The Jo…
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psnet.ahrq.gov/node/47508/psn-pdf
October 24, 2018 - Root cause analysis of reported patient falls in ORs in the
Veterans Health Administration.
October 24, 2018
Soncrant CM, Warner LJ, Neily J, et al. Root Cause Analysis of Reported Patient Falls in ORs in the
Veterans Health Administration. AORN J. 2018;108(4):386-397. doi:10.1002/aorn.12372.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/47054/psn-pdf
July 19, 2018 - A target to achieve zero preventable trauma deaths
through quality improvement.
July 19, 2018
Hashmi ZG, Haut ER, Efron DT, et al. A Target to Achieve Zero Preventable Trauma Deaths Through
Quality Improvement. JAMA Surg. 2018;153(7):686-689. doi:10.1001/jamasurg.2018.0159.
https://psnet.ahrq.gov/issue/target-achi…