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psnet.ahrq.gov/node/45023/psn-pdf
April 17, 2018 - Lean Hospitals: Improving Quality, Patient Safety, and
Employee Engagement, Third Edition.
April 17, 2018
Graban M. Boca Raton, FL: Productivity Press; 2016. ISBN: 9781498743259.
https://psnet.ahrq.gov/issue/lean-hospitals-improving-quality-patient-safety-and-employee-engagement-
third-edition
Lean methodology fo…
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psnet.ahrq.gov/node/41556/psn-pdf
January 03, 2017 - Patient safety reporting systems: sustained quality
improvement using a multidisciplinary team and "Good
Catch" awards.
January 3, 2017
Herzer KR, Mirrer M, Xie Y, et al. Patient Safety Reporting Systems: Sustained Quality Improvement Using
a Multidisciplinary Team and “Good Catch” Awards. Jt Comm J Qual Patient S…
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psnet.ahrq.gov/node/46303/psn-pdf
November 21, 2017 - How do hospital boards govern for quality improvement?
A mixed methods study of 15 organisations in England.
November 21, 2017
Jones L, Pomeroy L, Robert G, et al. How do hospital boards govern for quality improvement? A mixed
methods study of 15 organisations in England. BMJ Qual Saf. 2017;26(12):978-986. doi:10.1…
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psnet.ahrq.gov/node/45004/psn-pdf
April 06, 2016 - Using the Targeted Solutions Tool to improve hand
hygiene compliance is associated with decreased health
care–associated infections.
April 6, 2016
Shabot M, Chassin MR, France A-C, et al. Using the Targeted Solutions Tool® to Improve Hand Hygiene
Compliance Is Associated with Decreased Health Care-Associated Infec…
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psnet.ahrq.gov/node/74718/psn-pdf
February 02, 2022 - Medication-related interventions to improve medication
safety and patient outcomes on transition from adult
intensive care settings: a systematic review and meta-
analysis.
February 2, 2022
Bourne RS, Jennings JK, Panagioti M, et al. Medication-related interventions to improve medication safety
and patient outcom…
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psnet.ahrq.gov/node/42705/psn-pdf
November 26, 2013 - Improving America's Hospitals: The Joint Commission's
Annual Report on Quality and Safety 2013.
November 26, 2013
Oakbrook Terrace, IL: The Joint Commission; October 2013.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-
safety-2013
This Joint Commission…
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psnet.ahrq.gov/node/72803/psn-pdf
March 03, 2021 - First do no harm: practitioners' ability to 'diagnose'
system weaknesses and improve safety is a critical initial
step in improving care quality.
March 3, 2021
English M, Ogola M, Aluvaala J, et al. First do no harm: practitioners’ ability to ‘diagnose’ system
weaknesses and improve safety is a critical initial st…
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psnet.ahrq.gov/node/44577/psn-pdf
October 21, 2015 - Improving patient safety in clinical oncology: applying
lessons from Normal Accident Theory.
October 21, 2015
Chera BS, Mazur L, Buchanan I, et al. Improving Patient Safety in Clinical Oncology: Applying Lessons
From Normal Accident Theory. JAMA Oncol. 2015;1(7):958-64. doi:10.1001/jamaoncol.2015.0891.
https://psn…
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psnet.ahrq.gov/node/838126/psn-pdf
September 21, 2022 - Sustained improvement in quality of patient handoffs
after orthopaedic surgery I-PASS intervention.
September 21, 2022
Stenquist DS, Yeung CM, Szapary HJ, et al. Sustained improvement in quality of patient handoffs after
orthopaedic surgery I-PASS intervention. J Am Acad Orthop Surg Glob Res Rev. 2022;6(9):e22.0007…
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psnet.ahrq.gov/node/37091/psn-pdf
March 02, 2016 - The tension between needing to improve care and
knowing how to do it.
March 2, 2016
Auerbach AD, Landefeld S, Shojania KG. The tension between needing to improve care and knowing how
to do it. N Engl J Med. 2007;357(6):608-13.
https://psnet.ahrq.gov/issue/tension-between-needing-improve-care-and-knowing-how-do-it
…
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psnet.ahrq.gov/node/73363/psn-pdf
June 09, 2021 - Shift-to-shift nursing handover interventions associated
with improved inpatient outcomes - falls, pressure
injuries and medication administration errors: an
integrative review.
June 9, 2021
Hada A, Coyer F. Shift?to?shift nursing handover interventions associated with improved inpatient
outcomes—falls, pressure …
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psnet.ahrq.gov/node/44680/psn-pdf
February 24, 2018 - Measurement is essential for improving diagnosis and
reducing diagnostic error: a report from the Institute of
Medicine.
February 24, 2018
McGlynn EA, McDonald KM, Cassel C. Measurement Is Essential for Improving Diagnosis and Reducing
Diagnostic Error: A Report From the Institute of Medicine. JAMA. 2015;314(23):2…
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psnet.ahrq.gov/node/47714/psn-pdf
March 27, 2019 - Quality improvement in ambulatory surgery centers: a
major national effort aimed at reducing infections and
other surgical complications.
March 27, 2019
Davis KK, Mahishi V, Singal R, et al. Quality Improvement in Ambulatory Surgery Centers: A Major
National Effort Aimed at Reducing Infections and Other Surgical C…
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psnet.ahrq.gov/node/854636/psn-pdf
October 18, 2023 - Primary care teams' reported actions to improve
medication safety: a qualitative study with insights in
high reliability organising.
October 18, 2023
Young RA, Gurses AP, Fulda KG, et al. Primary care teams’ reported actions to improve medication safety:
a qualitative study with insights in high reliability organi…
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psnet.ahrq.gov/node/73676/psn-pdf
September 08, 2021 - Organizational readiness to change as a leverage point
for improving safety: a national nursing home survey.
September 8, 2021
Quach ED, Kazis LE, Zhao S, et al. Organizational readiness to change as a leverage point for improving
safety: a national nursing home survey. BMC Health Serv Res. 2021;21(1):842. doi:10.1…
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psnet.ahrq.gov/node/72857/psn-pdf
March 17, 2021 - Results and lessons from a hospital-wide initiative
incentivised by delivery system reform to improve
infection prevention and sepsis care.
March 17, 2021
Sreeramoju P, Voy-Hatter K, White C, et al. Results and lessons from a hospital-wide initiative incentivised
by delivery system reform to improve infection prev…
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psnet.ahrq.gov/node/847546/psn-pdf
March 25, 2021 - Patient safety culture improves during an in situ
simulation intervention: a repeated cross-sectional
intervention study at two hospital sites.
March 25, 2021
Schram A, Paltved C, Christensen KB, et al. Patient safety culture improves during an in situ simulation
intervention: a repeated cross-sectional interventi…
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psnet.ahrq.gov/node/73346/psn-pdf
June 02, 2021 - Human factors and ergonomics to improve performance
in intensive care units during the COVID-19 pandemic.
June 2, 2021
Della Torre V, E. Nacul F, Rosseel P, et al. Human factors and ergonomics to improve performance in
intensive care units during the COVID-19 pandemic. Anaesthesiol Intensive Ther. 2021;53(3):265-27…
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psnet.ahrq.gov/node/60249/psn-pdf
April 22, 2020 - Interventions designed to improve the safety and quality
of therapeutic anticoagulation in an inpatient electronic
medical record.
April 22, 2020
Austin J, Barras M, Sullivan C. Interventions designed to improve the safety and quality of therapeutic
anticoagulation in an inpatient electronic medical record. Int J …
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psnet.ahrq.gov/node/50935/psn-pdf
February 26, 2020 - Moving from knowledge to action: improving safety and
quality of care for patients with limited English
proficiency.
February 26, 2020
Fox MT, Godage SK, Kim JM, et al. Moving from knowledge to action: improving safety and quality of care
for patients with limited English proficiency. Clin Pediatr (Phila). 2020;59…