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psnet.ahrq.gov/node/44551/psn-pdf
September 30, 2015 - Safety culture includes "good catches."
September 30, 2015
Traynor K. Safety culture includes "good catches". Am J Health Syst Pharm. 2015;72(19):1597-1599.
doi:10.2146/news150065.
https://psnet.ahrq.gov/issue/safety-culture-includes-good-catches
Near misses can provide opportunities for learning if there is a pro…
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psnet.ahrq.gov/node/42049/psn-pdf
February 20, 2013 - Mitigating error vulnerability at the transition of care
through the use of health IT applications.
February 20, 2013
Cortelyou-Ward K, Swain A, Yeung T. Mitigating Error Vulnerability at the Transition of Care through the
Use of Health IT Applications. J Med Syst. 2012;36(6). doi:10.1007/s10916-012-9855-x.
https:…
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psnet.ahrq.gov/node/45586/psn-pdf
November 02, 2016 - Antimicrobial stewardship and patient safety.
November 2, 2016
Zukowski CM. Antimicrobial Stewardship and Patient Safety. AORN J. 2016;104(4):354-356.
doi:10.1016/j.aorn.2016.08.002.
https://psnet.ahrq.gov/issue/antimicrobial-stewardship-and-patient-safety
Antimicrobial stewardship has been highlighted as a strate…
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psnet.ahrq.gov/node/44475/psn-pdf
October 03, 2017 - Scoring no goal—further adventures in transparency.
October 3, 2017
Rosenbaum L. Scoring No Goal--Further Adventures in Transparency. N Engl J Med. 2015;373(15):1385-
8. doi:10.1056/NEJMp1510094.
https://psnet.ahrq.gov/issue/scoring-no-goal-further-adventures-transparency
This commentary explores challenges to mon…
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psnet.ahrq.gov/node/852804/psn-pdf
August 23, 2023 - Five new ways to advance diagnostic safety in your
clinical practice.
August 23, 2023
Bradford A, Goeschel C, Shofer M, et al. Am Fam Physician. 2023;108(1):14-16.
https://psnet.ahrq.gov/issue/five-new-ways-advance-diagnostic-safety-your-clinical-practice
Diagnostic errors are common in the ambulatory environment.…
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psnet.ahrq.gov/node/838929/psn-pdf
October 26, 2022 - Toolkit To Improve Antibiotic Use in Ambulatory Care.
October 26, 2022
Rockville, MD: Agency for Healthcare Research and Quality; October 2022.
https://psnet.ahrq.gov/issue/toolkit-improve-antibiotic-use-ambulatory-care
Inappropriate antibiotic prescribing is associated with increased risk potential. This toolkit a…
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psnet.ahrq.gov/node/38276/psn-pdf
December 10, 2008 - Addressing delays in medication administration for
patients transferred from the hospital to the nursing
home: a pilot quality improvement project.
December 10, 2008
Ward KT, Bates-Jensen B, Eslami MS, et al. Addressing delays in medication administration for patients
transferred from the hospital to the nursing h…
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psnet.ahrq.gov/node/44793/psn-pdf
February 17, 2016 - The Sociology of Healthcare Safety and Quality.
February 17, 2016
Allen D, Braithwaite J, Sandall J, Waring J, eds. Sociol Health Illn. 2016;38(2):179-339.
https://psnet.ahrq.gov/issue/sociology-healthcare-safety-and-quality
The sociological approach to exploring safety has shown promise as a way to understand why …
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psnet.ahrq.gov/node/46295/psn-pdf
September 06, 2017 - Pain assessment and management standards for
hospitals.
September 6, 2017
R3 Report. August 29, 2017;11:1-7.
https://psnet.ahrq.gov/issue/pain-assessment-and-management-standards-hospitals
Strategies to manage pain safely have been reexamined in light of the opioid epidemic. This report
highlights Joint Commissio…
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psnet.ahrq.gov/node/50811/psn-pdf
January 15, 2020 - NHS hospitals to employ safety experts to tackle
thousands of avoidable mistakes.
January 15, 2020
Lintern S. NHS hospitals to employ safety experts to tackle thousands of avoidable mistakes. Independent.
December 25, 2019;
https://psnet.ahrq.gov/issue/nhs-hospitals-employ-safety-experts-tackle-thousands-avoidable…
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psnet.ahrq.gov/node/41026/psn-pdf
March 02, 2012 - SBAR: electronic handoff tool for noncomplicated
procedural patients.
March 2, 2012
Wentworth L, Diggins J, Bartel D, et al. SBAR: electronic handoff tool for noncomplicated procedural
patients. J Nurs Care Qual. 2012;27(2):125-31. doi:10.1097/NCQ.0b013e31823cc9a0.
https://psnet.ahrq.gov/issue/sbar-electronic-hand…
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psnet.ahrq.gov/node/850358/psn-pdf
June 14, 2023 - What Happened to Patient Safety.
June 14, 2023
Sheridan S. Turn on the Lights. Institute for Healthcare Improvement. May 2023
https://psnet.ahrq.gov/issue/what-happened-patient-safety
Patient engagement is an important component in patient safety. This episode from the Turn on the Lights
podcast (hosted by I…
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psnet.ahrq.gov/node/42551/psn-pdf
May 21, 2019 - Should medical malpractice prevention be considered
separately or as an integral part of comprehensive health
care safety improvement?
May 21, 2019
Enbom JA. Should medical malpractice prevention be considered separately or as an integral part of
comprehensive health care safety improvement? Am J Obstet Gynecol. 2…
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psnet.ahrq.gov/node/866530/psn-pdf
August 14, 2024 - Healthcare Simulation in Nursing Practice.
August 14, 2024
Watts PI. Healthcare Simulation in Nursing Practice. Nurs Clin North Am. 2024;59(3):345-510.
https://psnet.ahrq.gov/issue/healthcare-simulation-nursing-practice
Simulation is an established method to examine nursing process resilience and develop non-techni…
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psnet.ahrq.gov/node/74013/psn-pdf
October 27, 2021 - Applying decision science to the prioritization of
healthcare-associated infection initiatives.
October 27, 2021
Tsai TH, Gerst MD, Engineer C, et al. Applying decision science to the prioritization of healthcare-
associated infection initiatives. J Patient Saf. 2021;17(7):506-512. doi:10.1097/pts.0000000000000416.…
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psnet.ahrq.gov/node/46726/psn-pdf
January 31, 2018 - Toolkit to Promote Safe Surgery.
January 31, 2018
Rockville, MD: Agency for Healthcare Research and Quality; November 2017.
https://psnet.ahrq.gov/issue/toolkit-promote-safe-surgery
Preventing surgical complications including surgical site infections are a worldwide target for improvement.
This toolkit builds on t…
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psnet.ahrq.gov/node/45890/psn-pdf
February 15, 2017 - A Framework for Safe, Reliable, and Effective Care.
February 15, 2017
Frankel A, Haraden C, Federico F, Lenoci-Edwards J. Cambridge, MA: Institute for Healthcare
Improvement and Safe & Reliable Healthcare; 2017.
https://psnet.ahrq.gov/issue/framework-safe-reliable-and-effective-care
A systems approach to safety ca…
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psnet.ahrq.gov/node/848384/psn-pdf
May 03, 2023 - Roadmap to Health Care Safety for Massachusetts.
May 3, 2023
Massachusetts Healthcare Safety and Quality Consortium. Boston, MA: Betsy Lehman Center for Patient
Safety; April 2023.
https://psnet.ahrq.gov/issue/roadmap-health-care-safety-massachusetts
Collective engagement and focus are required to attain large sys…
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psnet.ahrq.gov/node/74076/psn-pdf
November 17, 2021 - Influence of perioperative handoffs on complications and
outcomes.
November 17, 2021
Burden AR, Potestio C, Pukenas E. Influence of perioperative handoffs on complications and outcomes.
Adv Anesth. 2021;39:133-148. doi:10.1016/j.aan.2021.07.008.
https://psnet.ahrq.gov/issue/influence-perioperative-handoffs-complic…
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psnet.ahrq.gov/node/41969/psn-pdf
July 02, 2014 - The creation and impact of a dedicated section on quality
and patient safety in a clinical academic department.
July 2, 2014
Boudreaux AM, Vetter TR. The Creation and Impact of a Dedicated Section on Quality and Patient Safety
in a Clinical Academic Department. Academic Medicine. 2012;88(2). doi:10.1097/acm.0b013e3…