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psnet.ahrq.gov/node/45901/psn-pdf
April 12, 2017 - Development and applications of the Veterans Health
Administration's Stratification Tool for Opioid Risk
Mitigation (STORM) to improve opioid safety and prevent
overdose and suicide.
April 12, 2017
Oliva EM, Bowe T, Tavakoli S, et al. Development and applications of the Veterans Health Administration's
Stratifica…
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psnet.ahrq.gov/node/43279/psn-pdf
October 20, 2014 - A comprehensive obstetric patient safety program
reduces liability claims and payments.
October 20, 2014
Pettker CM, Thung SF, Lipkind HS, et al. A comprehensive obstetric patient safety program reduces liability
claims and payments. Am J Obstet Gynecol. 2014;211(4):319-25. doi:10.1016/j.ajog.2014.04.038.
https://…
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psnet.ahrq.gov/node/45305/psn-pdf
February 14, 2017 - Sustaining reductions in central line-associated
bloodstream infections in Michigan intensive care units: a
10-year analysis.
February 14, 2017
Pronovost P, Watson S, Goeschel CA, et al. Sustaining Reductions in Central Line-Associated
Bloodstream Infections in Michigan Intensive Care Units: A 10-Year Analysis. Am…
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psnet.ahrq.gov/node/33796/psn-pdf
January 01, 2016 - In Conversation With… Mark L. Graber, MD
January 1, 2016
In Conversation With… Mark L. Graber, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
Editor's note: Dr. Graber is a Senior Fellow at RTI International and Professor Emeritus of Medicine at
the State University o…
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psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
October 30, 2024 - Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates
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February 9, 2021
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psnet.ahrq.gov/web-mm/hold-tpa
July 29, 2020 - Hold the tPA
Citation Text:
Fagan SC. Hold the tPA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Dow…
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psnet.ahrq.gov/primer/individual-clinician-performance-issues
March 15, 2025 - Individual Clinician Performance Issues
Citation Text:
Individual Clinician Performance Issues. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/867656/psn-pdf
February 26, 2025 - In Conversation with Lucy Savitz about Learning Health
Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. In Conversation with Lucy Savitz about Learning Health Systems for
Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learnin…
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psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
September 01, 2006 - Errors and Near Misses: What Health Care Could Learn From Aviation
Carl Macrae, PhD | December 1, 2016
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation…
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psnet.ahrq.gov/issue/improving-health-care-quality-and-safety-people-disabilities-interview-lisa-iezzoni
October 26, 2022 - Commentary
Improving health care quality and safety for people with disabilities: an interview with Lisa Iezzoni.
Citation Text:
Iezzoni LI. Improving health care quality and safety for people with disabilities: an interview with Lisa Iezzoni. Interview by Steven Berman. Jt Comm J Qual P…
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psnet.ahrq.gov/issue/improving-safety-operating-room-systematic-literature-review-retained-surgical-sponges
March 05, 2025 - Review
Improving safety in the operating room: a systematic literature review of retained surgical sponges.
Citation Text:
Wan W, Le T, Riskin L, et al. Improving safety in the operating room: a systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol. 2009;22(…
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psnet.ahrq.gov/issue/educational-intervention-increase-speaking-behaviors-nurses-and-improve-patient-safety
May 08, 2013 - Study
An educational intervention to increase "speaking-up" behaviors in nurses and improve patient safety.
Citation Text:
Sayre MM, McNeese-Smith D, Leach LS, et al. An educational intervention to increase "speaking-up" behaviors in nurses and improve patient safety. J Nurs Care Qual.…
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psnet.ahrq.gov/innovation/improving-formal-incivility-reporting-ambulatory-oncology-implementing-civic-duty
March 14, 2022 - EMERGING INNOVATIONS
Improving formal incivility reporting in ambulatory oncology: implementing the CIVIC Duty program.
Citation Text:
Gordon JN. Improving formal incivility reporting in ambulatory oncology: implementing the CIVIC Duty program. Clin J Oncol Nurs. 2023;27(6):602-606. doi:10.1188/23…
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psnet.ahrq.gov/issue/multifaceted-program-improving-quality-care-intensive-care-units-iatroref-study
April 12, 2011 - Study
A multifaceted program for improving quality of care in intensive care units: IATROREF study.
Citation Text:
Garrouste-Orgeas M, Soufir L, Tabah A, et al. A multifaceted program for improving quality of care in intensive care units: IATROREF study. Crit Care Med. 2012;40(2):468-7…
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psnet.ahrq.gov/issue/prospective-hazard-and-improvement-analytic-approach-predicting-effectiveness-medication
December 04, 2013 - Study
A prospective hazard and improvement analytic approach to predicting the effectiveness of medication error interventions.
Citation Text:
Karnon J, McIntosh A, Dean JE, et al. A prospective hazard and improvement analytic approach to predicting the effectiveness of medication erro…
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psnet.ahrq.gov/issue/sentara-norfolk-general-hospital-accelerating-improvement-focusing-building-culture-safety
June 08, 2010 - Commentary
Sentara Norfolk General Hospital: accelerating improvement by focusing on building a culture of safety.
Citation Text:
Yates GR, Hochman RF, Sayles SM, et al. Sentara Norfolk General Hospital: accelerating improvement by focusing on building a culture of safety. Jt Comm J Qu…
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psnet.ahrq.gov/issue/information-technology-interventions-improve-medication-safety-primary-care-systematic-review
July 29, 2020 - Review
Information technology interventions to improve medication safety in primary care: a systematic review.
Citation Text:
Lainer M, Mann E, Sönnichsen A. Information technology interventions to improve medication safety in primary care: a systematic review. Int J Qual Health Care. 20…
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psnet.ahrq.gov/issue/diagnostic-stewardship-improve-patient-outcomes-and-healthcare-associated-infection-hai
May 18, 2022 - Commentary
Diagnostic stewardship to improve patient outcomes and healthcare-associated infection (HAI) metrics.
Citation Text:
Singh HK, Claeys KC, Advani SD, et al. Diagnostic stewardship to improve patient outcomes and healthcare-associated infection (HAI) metrics. Infect Control Hosp…
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psnet.ahrq.gov/issue/reporting-medical-errors-improve-patient-safety-survey-physicians-teaching-hospitals
February 24, 2011 - Study
Reporting medical errors to improve patient safety: a survey of physicians in teaching hospitals.
Citation Text:
Kaldjian LC, Jones EW, Wu BJ, et al. Reporting medical errors to improve patient safety: a survey of physicians in teaching hospitals. Arch Intern Med. 2008;168(1):40-…
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psnet.ahrq.gov/issue/improving-medication-management-through-redesign-hospital-code-cart-medication-drawer
October 31, 2018 - Study
Improving medication management through the redesign of the hospital code cart medication drawer.
Citation Text:
Rousek JB, Hallbeck MS. Improving Medication Management Through the Redesign of the Hospital Code Cart Medication Drawer. Human Factors: The Journal of the Human Facto…