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psnet.ahrq.gov/node/38278/psn-pdf
January 15, 2009 - The impact of introducing medical emergency team
system on the documentations of vital signs.
January 15, 2009
Chen J, Hillman KM, Bellomo R, et al. The impact of introducing medical emergency team system on the
documentations of vital signs. Resuscitation. 2008;80(1). doi:10.1016/j.resuscitation.2008.10.009.
http…
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psnet.ahrq.gov/node/42139/psn-pdf
March 27, 2013 - Personalised performance feedback reduces narcotic
prescription errors in a NICU.
March 27, 2013
Sullivan KM, Suh S, Monk H, et al. Personalised performance feedback reduces narcotic prescription
errors in a NICU. BMJ Qual Saf. 2013;22(3):256-62. doi:10.1136/bmjqs-2012-001089.
https://psnet.ahrq.gov/issue/personal…
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psnet.ahrq.gov/node/837076/psn-pdf
May 11, 2022 - AHRQ Challenge on Innovative Solutions To Update or
Re-Create TeamSTEPPS Videos.
May 11, 2022
Rockville, MD; Agency for Healthcare Research and Quality: April 2022.
https://psnet.ahrq.gov/issue/ahrq-challenge-innovative-solutions-update-or-re-create-teamstepps-videos
TeamSTEPPS promotes effective teamwork, collabo…
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psnet.ahrq.gov/node/45006/psn-pdf
April 06, 2016 - Quality and Patient Safety.
April 6, 2016
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/quality-and-patient-safety
The Agency for Healthcare Research and Quality has provided access to patient safety research,
information, and tools for nearly two decades. This website offers a wide rang…
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psnet.ahrq.gov/node/42631/psn-pdf
November 08, 2013 - "That was a close call": endorsing a broad definition of
near misses in health care.
November 8, 2013
Marks CM, Kasda E, Paine LA, et al. "That was a close call": endorsing a broad definition of near misses in
health care. Jt Comm J Qual Patient Saf. 2013;39(10):475-479.
https://psnet.ahrq.gov/issue/was-close-call…
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psnet.ahrq.gov/node/46210/psn-pdf
July 12, 2017 - Could emotional intelligence make patients safer?
July 12, 2017
Codier E, Codier DD. Could Emotional Intelligence Make Patients Safer? Am J Nurs. 2017;117(7):58-62.
doi:10.1097/01.NAJ.0000520946.39224.db.
https://psnet.ahrq.gov/issue/could-emotional-intelligence-make-patients-safer
Nontechnical skill development i…
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psnet.ahrq.gov/node/37675/psn-pdf
April 09, 2008 - Hospital progress in reducing error: the impact of
external interventions.
April 9, 2008
Hosford SB. Hospital progress in reducing error: the impact of external interventions. Hosp Top.
2008;86(1):9-19. doi:10.3200/HTPS.86.1.9-20.
https://psnet.ahrq.gov/issue/hospital-progress-reducing-error-impact-external-interv…
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psnet.ahrq.gov/node/839328/psn-pdf
November 02, 2022 - Quality and Safety.
November 2, 2022
Iyer R, Walker A, eds. Paediatr Anaesth. 2022;32(11):1176-1272.
https://psnet.ahrq.gov/issue/quality-and-safety-1
Progress made in the adoption of infrastructure, Safety I, and Safety II concepts in high- and middle- to
lower-income countries around the world support safe pedia…
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psnet.ahrq.gov/node/35345/psn-pdf
July 20, 2009 - Fixing healthcare from the inside, today.
July 20, 2009
Spear SJ. Fixing health care from the inside, today. Harv Bus Rev. 2005;83(9):78-91, 158.
https://psnet.ahrq.gov/issue/fixing-healthcare-inside-today
This commentary provides a broad overview of the issues facing health care systems in their efforts to
promot…
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psnet.ahrq.gov/node/47533/psn-pdf
June 19, 2019 - Patient Safety: A Health Affairs Briefing.
June 19, 2019
Project Hope.
https://psnet.ahrq.gov/issue/patient-safety-health-affairs-briefing
To Err Is Human was released almost 2 decades ago and continues to influence a growing area of study
aimed at improving health care and reducing medical error. This in-person a…
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psnet.ahrq.gov/node/42500/psn-pdf
August 14, 2013 - When should students learn about ethics,
professionalism and patient safety?
August 14, 2013
Walton M, Jeffery H, Van Staalduinen S, et al. When should students learn about ethics, professionalism
and patient safety? Clin Teach. 2013;10(4):224-9. doi:10.1111/tct.12029.
https://psnet.ahrq.gov/issue/when-should-stud…
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psnet.ahrq.gov/node/44387/psn-pdf
August 19, 2015 - Simulation in Surgical Training and Practice.
August 19, 2015
Brown KM, Paige JT, eds. Surg Clin North Am. 2015;95:695-918.
https://psnet.ahrq.gov/issue/simulation-surgical-training-and-practice
Simulation training is being used more broadly as an educational approach in health care. Articles in this
special issue…
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psnet.ahrq.gov/node/38561/psn-pdf
April 15, 2009 - Health-Care–Associated Infections in Hospitals:
Continuing Leadership Needed from HHS to Prioritize
Prevention Practices and Improve Data on These
Infections.
April 15, 2009
Subcommittee on Health Care, Committee on Finance, US Senate, Government Accountability Office,
GAO-09-516T (March 18, 2009)
https://psnet.…
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psnet.ahrq.gov/node/37793/psn-pdf
February 15, 2011 - Educating seniors to be patient safety self-advocates in
primary care.
February 15, 2011
Elder NC, Regan SL, Pallerla H, et al. Educating Seniors to Be Patient Safety Self-Advocates in Primary
Care. J Patient Saf. 2008;4(2). doi:10.1097/pts.0b013e318175d806.
https://psnet.ahrq.gov/issue/educating-seniors-be-patien…
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psnet.ahrq.gov/node/42327/psn-pdf
June 05, 2013 - Development and testing of tools to detect ambulatory
surgical adverse events.
June 5, 2013
Mull HJ, Borzecki A, Hickson K, et al. Development and testing of tools to detect ambulatory surgical
adverse events. J Patient Saf. 2013;9(2):96-102. doi:10.1097/PTS.0b013e31827d1a88.
https://psnet.ahrq.gov/issue/developme…
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psnet.ahrq.gov/node/60719/psn-pdf
July 22, 2020 - How real-time data can change the patient safety game.
July 22, 2020
Diesing G. How real-time data can change the patient safety game. J AHIMA. 2020;July 1.
https://psnet.ahrq.gov/issue/how-real-time-data-can-change-patient-safety-game
Use of data can improve the response of clinicians to patient concerns and deter…
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psnet.ahrq.gov/node/46385/psn-pdf
October 23, 2018 - The key to reducing doctors' misdiagnoses.
October 23, 2018
Landro L. Wall Street Journal. September 12, 2017.
https://psnet.ahrq.gov/issue/key-reducing-doctors-misdiagnoses
Misdiagnosis has gained recognition as an important patient safety problem. This newspaper article reports
on several areas of research and i…
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psnet.ahrq.gov/node/73098/psn-pdf
September 07, 2021 - Achieving Excellence in the Diagnosis of Acute
Cardiovascular Events: Proceedings of a Workshop–in
Brief.
September 7, 2021
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies
Press; 2021.
https://psnet.ahrq.gov/issue/achieving-excellence-diagnosis-acute-cardiovascula…
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psnet.ahrq.gov/node/836870/psn-pdf
April 26, 2022 - A Conversation Among Stakeholders on Medical
Malpractice.
April 6, 2022
Collaborative for Accountability and Improvement. April 26, 2022.
https://psnet.ahrq.gov/issue/conversation-among-stakeholders-medical-malpractice
Communication and resolution programs (CRP) can improve response to patients and families a…
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psnet.ahrq.gov/node/837001/psn-pdf
April 27, 2022 - Final Report of the Ockenden Review.
April 27, 2022
London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294.
https://psnet.ahrq.gov/issue/final-report-ockenden-review
Maternal and baby harm in healthcare is a sentinel event manifested by systemic failure. This report serves
as the final conclusions of an i…