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psnet.ahrq.gov/node/39257/psn-pdf
January 27, 2010 - Opportunities and Recommendations for State–Federal
Coordination to Improve Health System Performance: A
Focus on Patient Safety.
January 27, 2010
Buxbaum J. Portland, ME: National Academy for State Health Policy; January 2010.
https://psnet.ahrq.gov/issue/opportunities-and-recommendations-state-federal-coordinati…
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psnet.ahrq.gov/node/60627/psn-pdf
June 24, 2020 - Second opinions improve healthcare outcomes and
reduce costs.
June 24, 2020
Hébert AR. Second opinions improve healthcare outcomes and reduce costs. Employee Benefit News.
2020;June 8.
https://psnet.ahrq.gov/issue/second-opinions-improve-healthcare-outcomes-and-reduce-costs
Second opinions are a strategy for redu…
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psnet.ahrq.gov/node/37432/psn-pdf
November 29, 2009 - The Pennsylvania Learning Exchange: Helping States
Improve and Integrate Patient Safety
Initiatives—Summary Report.
November 29, 2009
Hanlon C; Rosenthal J. Portland, ME: National Academy for State Health Policy; 2007.
https://psnet.ahrq.gov/issue/pennsylvania-learning-exchange-helping-states-improve-and-integrate…
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psnet.ahrq.gov/node/50876/psn-pdf
April 22, 2021 - Veterans Accountability Improvement Act.
April 22, 2021
SB 1307, 117th Congress: 2021.
https://psnet.ahrq.gov/issue/veterans-accountability-improvement-act
Reporting clinicians who exhibit practice behaviors that are detrimental to safety is challenged by system
and cultural norms. This legislation aims to strengt…
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psnet.ahrq.gov/node/39915/psn-pdf
December 18, 2014 - Improving the quality of discharge communication with
an educational intervention.
December 18, 2014
Key-Solle M, Paulk E, Bradford K, et al. Improving the quality of discharge communication with an
educational intervention. Pediatrics. 2010;126(4):734-9. doi:10.1542/peds.2010-0884.
https://psnet.ahrq.gov/issue/im…
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psnet.ahrq.gov/node/40999/psn-pdf
January 01, 2012 - Improving patient safety via automated laboratory-based
adverse event grading.
December 15, 2011
Niland JC, Stiller T, Neat J, et al. Improving patient safety via automated laboratory-based adverse event
grading. J Am Med Inform Assoc. 2012;19(1):111-5. doi:10.1136/amiajnl-2011-000513.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/34991/psn-pdf
June 22, 2009 - Use of failure mode and effects analysis in improving the
safety of i.v. drug administration.
June 22, 2009
Adachi W, Lodolce AE. Use of failure mode and effects analysis in improving the safety of i.v. drug
administration. Am J Health Syst Pharm. 2005;62(9):917-20.
https://psnet.ahrq.gov/issue/use-failure-mode-an…
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psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
January 01, 2022 - Spotlight
Spotlight
False Assumptions Result in a Missed
Pneumothorax after Bronchoscopy with
Transbronchial Biopsy
Source and Credits
• This presentation is based on the September 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by:…
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psnet.ahrq.gov/issue/creating-learning-health-system-improving-diagnostic-safety-pragmatic-insights-us-health-care
May 12, 2021 - Study
Creating a learning health system for improving diagnostic safety: pragmatic insights from US health care organizations.
Citation Text:
Giardina TD, Shahid U, Mushtaq U, et al. Creating a learning health system for improving diagnostic safety: pragmatic insights from US health care…
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psnet.ahrq.gov/issue/using-lean-improve-medication-administration-safety-search-perfect-dose
September 16, 2015 - Study
Using Lean to improve medication administration safety: in search of the "perfect dose."
Citation Text:
Ching JM, Long C, Williams BL, et al. Using lean to improve medication administration safety: in search of the "perfect dose". Jt Comm J Qual Patient Saf. 2013;39(5):195-204.
C…
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psnet.ahrq.gov/issue/improving-shared-situation-awareness-high-risk-therapies-hospitalized-children
October 20, 2021 - Study
Improving shared situation awareness for high-risk therapies in hospitalized children.
Citation Text:
Sosa T, Mayer B, Chakkalakkal B, et al. Improving shared situation awareness for high-risk therapies in hospitalized children. Hosp Pediatr. 2022;12(1):37-46. doi:10.1542/hpeds.202…
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psnet.ahrq.gov/issue/multiple-component-patient-safety-intervention-english-hospitals-controlled-evaluation-second
February 23, 2011 - Study
Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase.
Citation Text:
Benning A, Dixon-Woods M, Nwulu U, et al. Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase. BMJ. 20…
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psnet.ahrq.gov/issue/hospital-testing-effectiveness-co-designed-educational-materials-improve-patient-and-visitor
February 28, 2024 - Study
Hospital testing of the effectiveness of co-designed educational materials to improve patient and visitor knowledge and confidence in reporting patient deterioration.
Citation Text:
King L, Belan I, Clark RA, et al. Hospital testing of the effectiveness of co-designed educational m…
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psnet.ahrq.gov/issue/competencies-improving-diagnosis-interprofessional-framework-education-and-training-health
September 12, 2018 - Study
Competencies for improving diagnosis: an interprofessional framework for education and training in health care.
Citation Text:
Olson A, Rencic J, Cosby K, et al. Competencies for improving diagnosis: an interprofessional framework for education and training in health care. Diagnosi…
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psnet.ahrq.gov/issue/tokenism-empowerment-progressing-patient-and-public-involvement-healthcare-improvement
March 18, 2020 - Review
From tokenism to empowerment: progressing patient and public involvement in healthcare improvement.
Citation Text:
Ocloo J, Matthews R. From tokenism to empowerment: progressing patient and public involvement in healthcare improvement. BMJ Qual Saf. 2016;25(8):626-32. doi:10.1136/…
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psnet.ahrq.gov/issue/use-positive-deviance-approach-improve-health-service-delivery-and-quality-care-scoping
May 29, 2024 - Review
The use of positive deviance approach to improve health service delivery and quality of care: a scoping review.
Citation Text:
Kassie AM, Eakin E, Abate BB, et al. The use of positive deviance approach to improve health service delivery and quality of care: a scoping review. BMC H…
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psnet.ahrq.gov/issue/development-core-drug-list-towards-improving-prescribing-education-and-reducing-errors-uk
April 13, 2022 - Study
Development of a core drug list towards improving prescribing education and reducing errors in the UK.
Citation Text:
Baker E, Pryce Roberts A, Wilde K, et al. Development of a core drug list towards improving prescribing education and reducing errors in the UK. Br J Clin Pharmac…
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psnet.ahrq.gov/issue/tracking-progress-improving-diagnosis-framework-defining-undesirable-diagnostic-events
September 01, 2021 - Commentary
Classic
Tracking progress in improving diagnosis: a framework for defining undesirable diagnostic events.
Citation Text:
Olson A, Graber ML, Singh H. Tracking Progress in Improving Diagnosis: A Framework for Defining Undesirable Diagnostic Events. J G…
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psnet.ahrq.gov/issue/characteristics-healthcare-organisations-struggling-improve-quality-results-systematic-review
August 14, 2019 - Review
Classic
Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies.
Citation Text:
Vaughn VM, Saint S, Krein SL, et al. Characteristics of healthcare organisations struggling to impro…
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psnet.ahrq.gov/issue/spreading-medication-administration-intervention-organizationwide-six-hospitals
January 03, 2017 - Study
Spreading a medication administration intervention organizationwide in six hospitals.
Citation Text:
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.
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