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psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
January 01, 2016 - In addition to improved measurement of diagnostic errors, these areas include clarifying responsibilities
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psnet.ahrq.gov/node/34804/psn-pdf
January 05, 2017 - Incident reporting system does not detect adverse drug
events: a problem for quality improvement.
January 5, 2017
Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug events:
a problem for quality improvement. Jt Comm J Qual Improv. 1995;21(10):541-8.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/39422/psn-pdf
March 23, 2011 - Organisational readiness: exploring the preconditions for
success in organisation-wide patient safety improvement
programmes.
March 23, 2011
Burnett S, Benn J, Pinto A, et al. Organisational readiness: exploring the preconditions for success in
organisation-wide patient safety improvement programmes. Qual Saf Heal…
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psnet.ahrq.gov/node/865878/psn-pdf
May 15, 2024 - Testing an intervention to improve health care worker
well-being during the COVID-19 pandemic: a cluster
randomized clinical trial.
May 15, 2024
Meredith LS, Ahluwalia SC, Chen PG, et al. Testing an intervention to improve health care worker well-
being during the COVID-19 pandemic: a cluster randomized clinical t…
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psnet.ahrq.gov/node/46565/psn-pdf
January 23, 2019 - Closing the Loop: A Guide to Safer Ambulatory Referrals
in the EHR Era.
January 23, 2019
Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for
Healthcare Improvement; 2017.
https://psnet.ahrq.gov/issue/closing-loop-guide-safer-ambulatory-referrals-ehr-era
Missed an…
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psnet.ahrq.gov/node/36163/psn-pdf
September 29, 2010 - Improving the bar-coded medication administration
system at the Department of Veterans Affairs.
September 29, 2010
Mills PD, Neily J, Mims E, et al. Improving the bar-coded medication administration system at the
Department of Veterans Affairs. Am J Health Syst Pharm. 2006;63(15):1442-7.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/837193/psn-pdf
May 25, 2022 - Defining diagnostic error: a scoping review to assess the
impact of the National Academies' report Improving
Diagnosis in Health Care.
May 25, 2022
Giardina TD, Hunte H, Hill MA, et al. Defining diagnostic error: a scoping review to assess the impact of the
National Academies' report Improving Diagnosis in Health …
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psnet.ahrq.gov/node/842416/psn-pdf
January 11, 2023 - A failure in the medication delivery system-how
disclosure and systems investigation improve patient
safety.
January 11, 2023
Lucas SR, Pollak E, Makowski C. A failure in the medication delivery system—how disclosure and systems
investigation improve patient safety. J Healthc Risk Manag. 2023;42(3-4):30-39. doi:10…
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psnet.ahrq.gov/node/866432/psn-pdf
August 07, 2024 - Improving appropriate use of peripherally inserted central
catheters through a statewide collaborative hospital
initiative: a cost-effectiveness analysis.
August 7, 2024
Heath M, Bernstein SJ, Paje D, et al. Improving appropriate use of peripherally inserted central catheters
through a statewide collaborative hosp…
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psnet.ahrq.gov/node/866554/psn-pdf
August 21, 2024 - Multi-team shared expectations tool (MT-SET): an
exercise to improve teamwork across health care teams.
August 21, 2024
Marsteller JA, Rosen MA, Wyskiel R, et al. Multi-team shared expectations tool (MT-SET): an exercise to
improve teamwork across health care teams. Jt Comm J Qual Patient Saf. 2024;50(10):737-744.
…
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psnet.ahrq.gov/node/39122/psn-pdf
January 03, 2017 - Empowering frontline nurses: a structured intervention
enables nurses to improve medication administration
accuracy.
January 3, 2017
Kliger J, Blegen MA, Gootee D, et al. Empowering frontline nurses: a structured intervention enables
nurses to improve medication administration accuracy. Jt Comm J Qual Patient Saf.…
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psnet.ahrq.gov/node/866584/psn-pdf
August 28, 2024 - Raising the barcode: improving medication safety
behaviours through a behavioural science-informed
feedback intervention. A quality improvement project and
difference-in-difference analysis.
August 28, 2024
Grailey K, Brazier A, Franklin BD, et al. Raising the barcode: improving medication safety behaviours
throu…
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psnet.ahrq.gov/node/43707/psn-pdf
November 26, 2014 - America's Hospitals: Improving Quality and Safety: The
Joint Commission's Annual Report 2014.
November 26, 2014
Oakbrook Terrace, IL: The Joint Commission; November 2014.
https://psnet.ahrq.gov/issue/americas-hospitals-improving-quality-and-safety-joint-commissions-annual-
report-2014
This Joint Commission annual…
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psnet.ahrq.gov/node/39691/psn-pdf
January 22, 2014 - Responsibility for quality improvement and patient safety:
hospital board and medical staff leadership challenges.
January 22, 2014
Goeschel CA, Wachter R, Pronovost P. Responsibility for quality improvement and patient safety: hospital
board and medical staff leadership challenges. Chest. 2010;138(1):171-8. doi:10…
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psnet.ahrq.gov/node/39699/psn-pdf
November 02, 2010 - Medical engagement in organisation-wide safety and
quality-improvement programmes: experience in the UK
Safer Patients Initiative.
November 2, 2010
Parand A, Burnett S, Benn J, et al. Medical engagement in organisation-wide safety and quality-
improvement programmes: experience in the UK Safer Patients Initiative.…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology1.html
April 01, 2025 - Exploration of Foundational Terminology and Paradigms for Improving Diagnosis
Introduction
Previous Page Next Page
Table of Contents
Exploration of Foundational Terminology and Paradigms for Improving Diagnosis
Introduction
Perspectives on Diagnostic Improvement
Definitions of Diagnosis
Type…
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psnet.ahrq.gov/perspective/workplace-safety-health-care
January 01, 2017 - It describes a repeatable process and structure that, we believe, can lead to improved safety in a variety
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psnet.ahrq.gov/issue/ahrq-funded-patient-safety-project-highlights-improving-healthcare-safety-engaging-patients
March 22, 2024 - Book/Report
AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Engaging Patients and Families.
Citation Text:
AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Engaging Patients and Families. Rockville, MD: Agency for Healthcare Rese…
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psnet.ahrq.gov/issue/ongoing-quality-improvement-journey-next-stop-high-reliability
January 23, 2012 - Commentary
The ongoing quality improvement journey: next stop, high reliability.
Citation Text:
Chassin MR, Loeb JM. The ongoing quality improvement journey: next stop, high reliability. Health Aff (Millwood). 2011;30(4):559-68. doi:10.1377/hlthaff.2011.0076.
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Format…
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psnet.ahrq.gov/issue/americas-hospitals-improving-quality-and-safety-joint-commissions-annual-report-2014
November 23, 2016 - Book/Report
America's Hospitals: Improving Quality and Safety: The Joint Commission's Annual Report 2014.
Citation Text:
America's Hospitals: Improving Quality and Safety: The Joint Commission's Annual Report 2014. Oakbrook Terrace, IL: The Joint Commission; November 2014.
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