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psnet.ahrq.gov/node/837192/psn-pdf
May 25, 2022 - Declaration to Advance Patient Safety.
May 25, 2022
National Steering Committee for Patient Safety. Boston, MA: Institute for Healthcare Improvement; May
2022.
https://psnet.ahrq.gov/issue/declaration-advance-patient-safety
Leadership commitment is crucial to attaining sustainable improvement in patient safety. Th…
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digital.ahrq.gov/ahrq-funded-projects/using-information-technology-it-improve-medication-safety-rural-elders/final-report
January 01, 2023 - Using Information Technology (IT) to Improve Medication Safety for Rural Elders - Final Report
Citation
Gorman P, Ordelheide K. Using Information Technology (IT) to Improve Medication Safety for Rural Elders - Final Report. (Prepared by Samaritan North Lincoln Hospital under Grant No. UC1 HS014928). …
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digital.ahrq.gov/ahrq-funded-projects/using-electronic-data-improve-care-patients-known-or-suspected-cancer/final-report
January 01, 2023 - Using Electronic Data to Improve Care of Patients With Known or Suspected Cancer - Final Report
Citation
Singh H. Using Electronic Data to Improve Care of Patients With Known or Suspected Cancer - Final Report. (Prepared by Baylor College of Medicine under Grant No. R18 HS017820). Rockville, MD: Agenc…
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digital.ahrq.gov/ahrq-funded-projects/electronic-records-improve-care-children/final-report
January 01, 2023 - Electronic Records to Improve Care for Children - Final Report
Citation
Shiffman R. Electronic Records to Improve Care for Children - Final Report. (Prepared by Yale University under Grant No. UC1 HS015420). Rockville, MD: Agency for Healthcare Research and Quality, 2008.
PDF
Electronic …
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digital.ahrq.gov/ahrq-funded-projects/tailored-dvd-improve-medication-management-low-literate-elderly-patients/final-report
January 01, 2023 - Tailored DVD to Improve Medication Management for Low Literate Elderly Patients - Final Report
Citation
Lapane, K. Tailored DVD to Improve Medication Management for Low Literate Elderly Patients - Final Report. (Prepared by Virginia Commonwealth University under Grant No. R18 HS017281). Rockville, MD:…
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psnet.ahrq.gov/node/46082/psn-pdf
February 25, 2019 - The opioid crisis: can improving diagnosis help solve the
problem?
February 25, 2019
Carr S. ImproveDx. April 2017;4:1-4.
https://psnet.ahrq.gov/issue/opioid-crisis-can-improving-diagnosis-help-solve-problem
The opioid epidemic has been widely discussed, but little research has examined how misdiagnosis can
contr…
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psnet.ahrq.gov/node/34935/psn-pdf
June 23, 2009 - Improving patient care. The cognitive psychology of
missed diagnoses.
June 23, 2009
Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med.
2005;142(2):115-120.
https://psnet.ahrq.gov/issue/improving-patient-care-cognitive-psychology-missed-diagnoses
This case study de…
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psnet.ahrq.gov/node/44919/psn-pdf
March 30, 2016 - Rapid response teams improve outcomes—Part 1, Part 2,
and Part 3.
March 30, 2016
Intensive Care Med. 2016;42(4):591-601.
https://psnet.ahrq.gov/issue/rapid-response-teams-improve-outcomes-part-1-part-2-and-part-3
This three-part commentary presents differing views on whether rapid response teams (RRTs) improve
pa…
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psnet.ahrq.gov/node/43701/psn-pdf
July 03, 2016 - Blink or think: can further reflection improve initial
diagnostic impressions?
July 3, 2016
Hess BJ, Lipner RS, Thompson V, et al. Blink or think: can further reflection improve initial diagnostic
impressions? Acad Med. 2015;90(1):112-118. doi:10.1097/ACM.0000000000000550.
https://psnet.ahrq.gov/issue/blink-or-thi…
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psnet.ahrq.gov/node/39042/psn-pdf
July 13, 2010 - Global oximetry: an international anaesthesia quality
improvement project.
July 13, 2010
Walker IA, Merry AF, Wilson IH, et al. Global oximetry: an international anaesthesia quality improvement
project. Anaesthesia. 2009;64(10):1051-60. doi:10.1111/j.1365-2044.2009.06067.x.
https://psnet.ahrq.gov/issue/global-oxim…
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psnet.ahrq.gov/node/43372/psn-pdf
April 13, 2016 - A case for improving measurement of intraoperative
iatrogenic injuries.
April 13, 2016
Paruch JL, Ko CY, Bilimoria KY. A case for improving measurement of intraoperative iatrogenic injuries.
JAMA Surg. 2014;149(9):887-8. doi:10.1001/jamasurg.2013.5237.
https://psnet.ahrq.gov/issue/case-improving-measurement-intrao…
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psnet.ahrq.gov/node/46427/psn-pdf
April 04, 2018 - Improving Diagnosis in Radiology—Progress and
Proposals.
April 4, 2018
Bruno MA, Johnson K, Argy N, Graber ML, eds. Diagnosis. 2017;4(3):111-191.
https://psnet.ahrq.gov/issue/improving-diagnosis-radiology-progress-and-proposals
Radiology plays a unique role in the determination of a diagnosis. Cognitive and system…
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psnet.ahrq.gov/node/865933/psn-pdf
May 22, 2024 - Utilizing pharmacogenomic testing can improve
medication safety and prevent harm.
May 22, 2024
ISMP Medication Safety Alert! Acute Care. 2024;29(9):1-4.
https://psnet.ahrq.gov/issue/utilizing-pharmacogenomic-testing-can-improve-medication-safety-and-
prevent-harm
Pharmacogenomics (PGx) refers to the impact of gen…
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psnet.ahrq.gov/node/46243/psn-pdf
June 05, 2019 - AHRQ Safety Program for Improving Surgical Care and
Recovery.
June 5, 2019
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/ahrq-safety-program-improving-surgical-care-and-recovery
Patients are vulnerable to harm after surgery. This program used methods from the Comprehensive Unit-
based S…
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psnet.ahrq.gov/node/38363/psn-pdf
February 23, 2009 - Critical care checklists, the Keystone Project, and the
Office for Human Research Protections: a case for
streamlining the approval process in quality-improvement
research.
February 23, 2009
Savel RH, Goldstein EB, Gropper MA. Critical care checklists, the Keystone Project, and the Office for
Human Research Prote…
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psnet.ahrq.gov/node/45923/psn-pdf
April 19, 2017 - Huddles and debriefings: improving communication on
labor and delivery.
April 19, 2017
McQuaid-Hanson E, Pian-Smith MCM. Huddles and Debriefings: Improving Communication on Labor and
Delivery. Anesthesiol Clin. 2017;35(1):59-67. doi:10.1016/j.anclin.2016.09.006.
https://psnet.ahrq.gov/issue/huddles-and-debriefings…
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psnet.ahrq.gov/node/74114/psn-pdf
November 24, 2021 - Addressing health care disparities by improving quality
and safety.
November 24, 2021
Sentinel Event Alert. Nov 10 2021;(64):1-7.
https://psnet.ahrq.gov/issue/addressing-health-care-disparities-improving-quality-and-safety
Health care disparities are emerging as a core patient safety issue. This alert introduces s…
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psnet.ahrq.gov/node/45642/psn-pdf
November 09, 2016 - Rethinking medical ward quality.
November 9, 2016
Pannick S, Wachter R, Vincent CA, et al. Rethinking medical ward quality. BMJ. 2016;355:i5417.
doi:10.1136/bmj.i5417.
https://psnet.ahrq.gov/issue/rethinking-medical-ward-quality
Patient safety research and commentary often focus on specialized care processes rathe…
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psnet.ahrq.gov/node/42161/psn-pdf
April 03, 2013 - Positioning continuing education: boundaries and
intersections between the domains continuing education,
knowledge translation, patient safety and quality
improvement.
April 3, 2013
Kitto S, Bell M, Peller J, et al. Positioning continuing education: boundaries and intersections between the
domains continuing educ…
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psnet.ahrq.gov/node/43022/psn-pdf
May 29, 2014 - Using simulation to improve root cause analysis of
adverse surgical outcomes.
May 29, 2014
Slakey DP, Simms ER, Rennie K, et al. Using simulation to improve root cause analysis of adverse surgical
outcomes. Int J Qual Health Care. 2014;26(2):144-50. doi:10.1093/intqhc/mzu011.
https://psnet.ahrq.gov/issue/using-sim…