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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866857/psn-pdf
    October 02, 2024 - Reducing falls in hospitalized children and adolescents with cancer and blood disorders: a quality improvement journey. October 2, 2024 Morrissey LK, Ho P, Ilowite M, et al. Reducing falls in hospitalized children and adolescents with cancer and blood disorders: a quality improvement journey. Pediatr Qual Saf. 202…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46227/psn-pdf
    October 30, 2017 - Patient engagement with surgical site infection prevention: an expert panel perspective. October 30, 2017 Tartari E, Weterings V, Gastmeier P, et al. Patient engagement with surgical site infection prevention: an expert panel perspective. Antimicrob Resist Infect Control. 2017;6:45. doi:10.1186/s13756-017-0202-3. …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74856/psn-pdf
    February 23, 2022 - The secondary use of data to support medication safety in the hospital setting: a systematic review and narrative synthesis. February 23, 2022 Chaudhry NT, Franklin BD, Mohammed S, et al. The secondary use of data to support medication safety in the hospital setting: a systematic review and narrative synthesis. Ph…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45935/psn-pdf
    September 29, 2017 - Radiology research in quality and safety: current trends and future needs. September 29, 2017 Zygmont ME, Itri JN, Rosenkrantz AB, et al. Radiology Research in Quality and Safety: Current Trends and Future Needs. Acad Radiol. 2017;24(3):263-272. doi:10.1016/j.acra.2016.07.021. https://psnet.ahrq.gov/issue/radiolog…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46825/psn-pdf
    June 19, 2018 - Diagnostic performance dashboards: tracking diagnostic errors using big data. June 19, 2018 Mane KK, Rubenstein KB, Nassery N, et al. Diagnostic performance dashboards: tracking diagnostic errors using big data. BMJ Qual Saf. 2018;27(7):567-570. doi:10.1136/bmjqs-2018-007945. https://psnet.ahrq.gov/issue/diagnosti…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46577/psn-pdf
    April 03, 2018 - The new diagnostic team. April 3, 2018 Graber ML, Rusz D, Jones ML, et al. The new diagnostic team. Diagnosis (Berl). 2017;4(4):225-238. doi:10.1515/dx-2017-0022. https://psnet.ahrq.gov/issue/new-diagnostic-team Teamwork has been highlighted as a key component of patient safety that also applies to improving diag…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44867/psn-pdf
    March 23, 2016 - Understanding why quality initiatives succeed or fail: a sociotechnical systems perspective. March 23, 2016 Wiegmann DA. Understanding Why Quality Initiatives Succeed or Fail: A Sociotechnical Systems Perspective. Ann Surg. 2016;263(1):9-11. doi:10.1097/SLA.0000000000001333. https://psnet.ahrq.gov/issue/understand…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837910/psn-pdf
    August 24, 2022 - How Safe is Your Care? Measurement and Monitoring of Safety Through the Eyes of Patients and Their Care Partners. August 24, 2022 Jefs L, Kuluski K, MacLaurin A, et al. Ottawa, Ontario, Canada: Healthcare Excellence Canada; 2022. https://psnet.ahrq.gov/issue/how-safe-your-care-measurement-and-monitoring-safety-thr…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50910/psn-pdf
    February 19, 2020 - SEIPS 3.0: human-centered design of the patient journey for patient safety. February 19, 2020 Carayon P, Wooldridge AR, Hoonakker P, et al. SEIPS 3.0: human-centered design of the patient journey for patient safety. App Ergon. 2020;84:103033. doi:10.1016/j.apergo.2019.103033. https://psnet.ahrq.gov/issue/seips-30-…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48180/psn-pdf
    August 21, 2019 - Burnout and Resilience and Quality and Safety Programs in Obstetrics and Gynecology. August 21, 2019 Main EK, Fowler JM, Gabbe SG, eds. Clin Obstet Gynecol. 2019;62:vii-xii,403-626. https://psnet.ahrq.gov/issue/burnout-and-resilience-and-quality-and-safety-programs-obstetrics-and- gynecology Obstetrics is a high-…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47431/psn-pdf
    September 26, 2018 - Partnering with pediatric patients and families in high reliability to identify and reduce preventable safety events. September 26, 2018 Kirby J, Cannon C, Darrah L, et al. Patient Exp J. 2018;5:76-90. https://psnet.ahrq.gov/issue/partnering-pediatric-patients-and-families-high-reliability-identify-and-reduce- pr…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72501/psn-pdf
    November 25, 2020 - Use of an audit with feedback implementation strategy to promote medication error reporting by nurses. November 25, 2020 Hutchinson A, Brotto V, Chapman A, et al. Use of an audit with feedback implementation strategy to promote medication error reporting by nurses. J Clin Nurs. 2020;29(21-22):4180-4193. doi:10.111…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33663/psn-pdf
    September 15, 2008 - Implementing a Patient Safety Program at a Large National Health System January 1, 2008 Hauck LD, Jacob J. Implementing a Patient Safety Program at a Large National Health System. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system Perspectiv…
  14. psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety
    November 10, 2015 - Are We Getting Better at Measuring Patient Safety? Amy K. Rosen, PhD | November 1, 2010  View more articles from the same authors. Citation Text: Rosen AK. Are We Getting Better at Measuring Patient Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare R…
  15. psnet.ahrq.gov/perspective/conversation-withsorrel-king
    March 01, 2007 - In Conversation with...Sorrel King March 1, 2007  Also Read an Essay Citation Text: In Conversation with..Sorrel King. PSNet [internet]. 2007.In Conversation with...Sorrel King. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
  16. psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
    January 01, 2020 - Spotlight Too Many Cooks in the Kitchen Source and Credits • This presentation is based on the August 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Richard P. Dutton, MD, MBA o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33786/psn-pdf
    May 01, 2015 - Video to Improve Patient Safety: Clinical and Educational Uses May 1, 2015 Xiao Y, Mackenzie CF, Seagull JF. Video to Improve Patient Safety: Clinical and Educational Uses. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses Perspective Reports of…
  18. psnet.ahrq.gov/perspective/maternal-safety
    January 01, 2015 - Annual Perspective Maternal Safety Audrey Lyndon, RN, PhD | December 22, 2018  View more articles from the same authors. Citation Text: Lyndon A. Maternal Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of H…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867845/psn-pdf
    February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary February 26, 2025 https://psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation- summary Summary This innovation describes the Veteran Health Administration (VHA) National Center for Patient Saf…
  20. psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
    March 01, 2007 - The Soil, Not the Seed: The Real Problem with Root Cause Analysis Patrice Spath, BA, RHIT, and William Minogue, MD | July 1, 2008  View more articles from the same authors. Citation Text: Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause …

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