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psnet.ahrq.gov/node/46372/psn-pdf
September 13, 2017 - Impact of a successful speaking up program on health-
care worker hand hygiene behavior.
September 13, 2017
Linam MW; Honeycutt MD; Gilliam CH; Wisdom CM; Deshpande JK.
https://psnet.ahrq.gov/issue/impact-successful-speaking-program-health-care-worker-hand-hygiene-
behavior
Improving hand hygiene in health care f…
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psnet.ahrq.gov/node/850910/psn-pdf
June 21, 2023 - Developing electronic clinical quality measures to assess
the cancer diagnostic process.
June 21, 2023
Murphy DR, Zimolzak AJ, Upadhyay DK, et al. Developing electronic clinical quality measures to assess
the cancer diagnostic process. J Am Med Inform Assoc. 2023;30(9):1526-1531.
doi:10.1093/jamia/ocad089.
https:…
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psnet.ahrq.gov/node/866959/psn-pdf
October 16, 2024 - A review of incidents related to health information
technology in Swedish healthcare to characterise system
issues as a basis for improvement in clinical practice.
October 16, 2024
Pan D, Nilsson E, Rahman Jabin MS. A review of incidents related to health information technology in
Swedish healthcare to characteris…
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psnet.ahrq.gov/issue/centre-patient-safety-and-service-quality
August 01, 2024 - Multi-use Website
Centre for Patient Safety and Service Quality.
Save
Save to your library
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February 17, 2009
This research program was established to explo…
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psnet.ahrq.gov/node/45152/psn-pdf
November 18, 2016 - Department of Veterans Affairs Chief Resident in Quality
and Patient Safety Program: a model to spread change.
November 18, 2016
Watts B, Paull DE, Williams LC, et al. Department of Veterans Affairs Chief Resident in Quality and Patient
Safety Program: A Model to Spread Change. Am J Med Qual. 2016;31(6):598-600.
h…
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psnet.ahrq.gov/node/73067/psn-pdf
March 24, 2021 - Changes in error patterns in unanticipated trauma deaths
during 20 years: in pursuit of zero preventable deaths.
March 24, 2021
LaGrone LN, McIntyre LK, Riggle A, et al. Changes in error patterns in unanticipated trauma deaths during
20 years: In pursuit of zero preventable deaths. J Trauma Acute Care Surg. 2020;89…
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psnet.ahrq.gov/node/47380/psn-pdf
September 05, 2018 - Operating management system for high reliability:
leadership, accountability, learning and innovation in
healthcare.
September 5, 2018
Day RM, Demski RJ, Pronovost PJ, et al. Operating management system for high reliability: Leadership,
accountability, learning and innovation in healthcare. J Patient Saf Risk Mana…
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psnet.ahrq.gov/node/47725/psn-pdf
March 06, 2019 - Overcoming human barriers to safety event reporting in
radiology.
March 6, 2019
Siewert B, Brook OR, Swedeen S, et al. Overcoming Human Barriers to Safety Event Reporting in
Radiology. Radiographics. 2019;39(1):251-263. doi:10.1148/rg.2019180135.
https://psnet.ahrq.gov/issue/overcoming-human-barriers-safety-event-…
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psnet.ahrq.gov/node/42115/psn-pdf
March 20, 2013 - Medication reconciliation during transitions of care as a
patient safety strategy: a systematic review.
March 20, 2013
Kwan JL, Lo L, Sampson M, et al. Medication reconciliation during transitions of care as a patient safety
strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):397-403. doi:10.7326/0003-4…
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psnet.ahrq.gov/node/44456/psn-pdf
September 02, 2015 - Tackling communication barriers between long-term care
facility and emergency department transfers to improve
medication safety in older adults.
September 2, 2015
Callinan SM, Brandt NJ. Tackling communication barriers between long-term care facility and emergency
department transfers to improve medication safety …
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psnet.ahrq.gov/node/72804/psn-pdf
March 03, 2021 - How to do no harm: empowering local leaders to make
care safer in low-resource settings.
March 3, 2021
Vincent CA, Mboga M, Gathara D, et al. How to do no harm: empowering local leaders to make care safer
in low-resource settings. Arch Dis Child. 2021;106(4):333-337. doi:10.1136/archdischild-2020-320631.
https://p…
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psnet.ahrq.gov/node/845348/psn-pdf
February 02, 2012 - Liquid-based Papanicolaou tests in endometrial
carcinoma diagnosis: performance, error root cause
analysis, and quality improvement.
February 2, 2012
Sams SB, Currens HS, Raab SS. Liquid-based Papanicolaou tests in endometrial carcinoma diagnosis:
performance, error root cause analysis, and quality improvement. Am…
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psnet.ahrq.gov/node/47909/psn-pdf
May 29, 2019 - Teaching novice clinicians how to reduce diagnostic
waste and errors by applying the Toyota Production
System.
May 29, 2019
Radhakrishnan NS, Singh H, Southwick FS. Teaching novice clinicians how to reduce diagnostic waste
and errors by applying the Toyota Production System. Diagnosis (Berl). 2019;6(2):179-185. do…
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psnet.ahrq.gov/node/854385/psn-pdf
October 11, 2023 - Perioperative team-based morbidity and mortality
conferences: a systematic review of the literature.
October 11, 2023
Samost-Williams A, Rosen R, Hannenberg A, et al. Perioperative team-based morbidity and mortality
conferences: a systematic review of the literature. Ann Surg Open. 2023;4(3):e321.
doi:10.1097/as9.…
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psnet.ahrq.gov/node/859349/psn-pdf
January 01, 2024 - Investigating the influence of selected leadership styles
on patient safety and quality of care: a systematic review
and meta-analysis.
December 20, 2023
Singh A, Yeravdekar R, Jadhav S. Investigating the influence of selected leadership styles on patient safety
and quality of care: a systematic review and meta-an…
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psnet.ahrq.gov/node/73114/psn-pdf
April 07, 2021 - Clinical and financial implications of second-opinion
surgical pathology review.
April 7, 2021
Johnson SM, Samulski TD, O’Connor SM, et al. Clinical and financial implications of second-opinion
surgical pathology review. Am J Clin Pathol. 2021;156(4):559-568. doi:10.1093/ajcp/aqaa263.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/41132/psn-pdf
March 13, 2012 - Spreading a medication administration intervention
organizationwide in six hospitals.
March 13, 2012
Kliger J, Singer SJ, Hoffman F, et al. Spreading a medication administration intervention organizationwide
in six hospitals. Jt Comm J Qual Patient Saf. 2012;38(2):51-60.
https://psnet.ahrq.gov/issue/spreading-medi…
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psnet.ahrq.gov/node/837796/psn-pdf
August 10, 2022 - Association between hospital acquired harm outcomes
and membership in a national patient safety collaborative.
August 10, 2022
Coffey M, Marino M, Lyren A, et al. Association between hospital acquired harm outcomes and
membership in a national patient safety collaborative. JAMA Pediatr. 2022;176(9):924-932.
doi:10…
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psnet.ahrq.gov/node/46142/psn-pdf
June 14, 2017 - Introducing a new junior doctor electronic weekend
handover on an orthopaedic ward.
June 14, 2017
Maroo S, Raj D. Introducing a New Junior Doctor Electronic Weekend Handover on an Orthopaedic Ward.
BMJ Qual Improv Rep. 2017;6(1). doi:10.1136/bmjquality.u212695.w5059.
https://psnet.ahrq.gov/issue/introducing-new-ju…
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psnet.ahrq.gov/node/867751/psn-pdf
March 12, 2025 - Epidemiology of diagnostic errors in pediatric emergency
departments using electronic triggers.
March 12, 2025
Mahajan P, White E, Shaw KN, et al. Epidemiology of diagnostic errors in pediatric emergency
departments using electronic triggers. Acad Emerg Med. 2025;Epub Jan 15. doi:10.1111/acem.15087.
https://psnet.…