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psnet.ahrq.gov/node/50729/psn-pdf
December 11, 2019 - Improving Diagnostic Quality & Safety/Reducing
Diagnostic Error: Measurement Considerations.
December 11, 2019
Washington DC; National Quality Forum: October 28, 2019.
https://psnet.ahrq.gov/issue/improving-diagnostic-quality-safetyreducing-diagnostic-error-measurement-
considerations
Efforts to track, understand…
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psnet.ahrq.gov/node/42089/psn-pdf
March 06, 2013 - Organizational culture: an important context for
addressing and improving hospital to community patient
discharge.
March 6, 2013
Hesselink G, Vernooij-Dassen M, Pijnenborg L, et al. Organizational culture: an important context for
addressing and improving hospital to community patient discharge. Med Care. 2013;51(…
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psnet.ahrq.gov/node/42782/psn-pdf
January 19, 2014 - Developing a medical emergency team running sheet to
improve clinical handoff and documentation.
January 19, 2014
Mardegan K, Heland M, Whitelock T, et al. Developing a medical emergency team running sheet to
improve clinical handoff and documentation. Jt Comm J Qual Patient Saf. 2013;39(12):570-575.
https://psnet…
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psnet.ahrq.gov/node/40248/psn-pdf
June 20, 2011 - Achieving quality improvement in the nursing home:
influence of nursing leadership on communication and
teamwork.
June 20, 2011
Vogelsmeier A, Scott-Cawiezell J. Achieving quality improvement in the nursing home: influence of nursing
leadership on communication and teamwork. J Nurs Care Qual. 2011;26(3):236-42.
d…
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psnet.ahrq.gov/node/40320/psn-pdf
March 30, 2011 - Effectiveness of an information technology intervention
to improve prophylactic antibacterial use in the
postoperative period.
March 30, 2011
Haynes K, Linkin DR, Fishman NO, et al. Effectiveness of an information technology intervention to
improve prophylactic antibacterial use in the postoperative period. Journa…
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psnet.ahrq.gov/curated-library/maternal-safety
January 31, 2024 - Breadcrumb
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team
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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/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/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/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/43349/psn-pdf
July 16, 2014 - Multifaceted interventions improve adherence to the
surgical checklist.
July 16, 2014
Putnam LR, Levy SM, Sajid M, et al. Multifaceted interventions improve adherence to the surgical checklist.
Surgery. 2014;156(2):336-344. doi:10.1016/j.surg.2014.03.032.
https://psnet.ahrq.gov/issue/multifaceted-interventions-imp…
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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/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/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/38660/psn-pdf
November 13, 2009 - Improving medication error reporting in hospice care.
November 13, 2009
Boyer R, McPherson ML, Deshpande G, et al. Improving medication error reporting in hospice care. Am J
Hosp Palliat Care. 2009;26(5):361-7. doi:10.1177/1049909109335145.
https://psnet.ahrq.gov/issue/improving-medication-error-reporting-hospice-c…
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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/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…