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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…
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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.
…
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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…
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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…
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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…
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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…
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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…
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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…
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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-…
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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-…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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 …