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psnet.ahrq.gov/node/867133/psn-pdf
November 13, 2024 - Designing an intervention to improve medication safety
for nursing home residents based on experiential
knowledge related to patient safety culture at the nursing
home front line: cocreative process study.
November 13, 2024
Juhl MH, Soerensen AL, Vardinghus-Nielsen H, et al. Designing an intervention to improve me…
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psnet.ahrq.gov/node/37856/psn-pdf
June 16, 2011 - Improving patient safety in intensive care units in
Michigan.
June 16, 2011
Pronovost P, Berenholtz SM, Goeschel CA, et al. Improving patient safety in intensive care units in
Michigan. J Crit Care. 2008;23(2):207-212. doi:10.1016/j.jcrc.2007.09.002.
https://psnet.ahrq.gov/issue/improving-patient-safety-intensive-…
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psnet.ahrq.gov/node/74098/psn-pdf
January 01, 2023 - Reducing failure to rescue rates in a paediatric in-patient
setting: a 9-year quality improvement study.
November 24, 2021
McHale S, Marufu TC, Manning JC, et al. Reducing failure to rescue rates in a paediatric in?patient setting:
a 9?year quality improvement study. Nurs Crit Care. 2023;28(1):72-79. doi:10.1111/ni…
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psnet.ahrq.gov/node/836955/psn-pdf
April 20, 2022 - The National Imperative to Improve Nursing Home
Quality: Honoring Our Commitment to Residents,
Families, and Staff.
April 20, 2022
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies
Press; 2022. ISBN: 9780309686259
https://psnet.ahrq.gov/issue/national-imperative-imp…
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psnet.ahrq.gov/node/866745/psn-pdf
September 18, 2024 - State of the Science and Future Directions to Improve
Diagnostic Safety in Older Adults.
September 18, 2024
Tran AK, Syed Q, Bierman AS, et al. State Of The Science And Future Directions To Improve Diagnostic
Safety In Older Adults. Rockville, MD: Agency for Healthcare Research and Quality; September 2024.
AHRQ Pu…
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psnet.ahrq.gov/node/60540/psn-pdf
November 01, 2016 - Quality improvement initiatives lead to reduction in
nulliparous term singleton vertex cesarean delivery rate.
November 1, 2016
Vadnais MA, Hacker MR, Shah NT, et al. Quality improvement initiatives lead to reduction in nulliparous
term singleton vertex cesarean delivery rate. Jt Comm J Qual Patient Saf. 2016;43(2)…
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psnet.ahrq.gov/node/36902/psn-pdf
June 09, 2010 - Patient handover from surgery to intensive care: using
Formula 1 pit-stop and aviation models to improve safety
and quality.
June 9, 2010
Catchpole K, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using
Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr …
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psnet.ahrq.gov/node/60612/psn-pdf
January 01, 2021 - COVID-19: patient safety and quality improvement skills
to deploy during the surge.
June 24, 2020
Staines A, Amalberti R, Berwick DM, et al. COVID-19: patient safety and quality improvement skills to
deploy during the surge. Int J Qual Health Care. 2021;33(1):mzaa050. doi:10.1093/intqhc/mzaa050.
https://psnet.ahrq…
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psnet.ahrq.gov/node/843329/psn-pdf
February 01, 2023 - Improving administration and documentation of enteral
nutrition support therapy in a Veteran Affairs health care
system: use of medication administration record and bar
code scanning technology.
February 1, 2023
Chew MM, Rivas S, Chesser M, et al. Improving administration and documentation of enteral nutrition
su…
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psnet.ahrq.gov/node/40364/psn-pdf
July 01, 2011 - Utilising improvement science methods to optimise
medication reconciliation.
April 13, 2011
White CM, Schoettker PJ, Conway PH, et al. Utilising improvement science methods to optimise
medication reconciliation. BMJ Qual Saf. 2011;20(4):372-80. doi:10.1136/bmjqs.2010.047845.
https://psnet.ahrq.gov/issue/utilising-…
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psnet.ahrq.gov/node/60027/psn-pdf
January 01, 2021 - Data-driven quality improvement, culture change, and the
high reliability journey at a special hospital for people
with medically complex developmental disabilities.
March 11, 2020
Barba V, Foreman K, Robey K. Data-driven quality improvement, culture change, and the high reliability
journey at a special hospital f…
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psnet.ahrq.gov/node/46678/psn-pdf
January 03, 2018 - Measuring patient safety in real time: an essential method
for effectively improving the safety of care.
January 3, 2018
Classen DC, Griffin FA, Berwick DM. Measuring Patient Safety in Real Time: An Essential Method for
Effectively Improving the Safety of Care. Ann Intern Med. 2017;167(12). doi:10.7326/m17-2202.
h…
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psnet.ahrq.gov/node/45651/psn-pdf
November 16, 2016 - Improving patient safety through the involvement of
patients: development and evaluation of novel
interventions to engage patients in preventing patient
safety incidents and protecting them against unintended
harm.
November 16, 2016
Wright J, Lawton R, O’Hara J, et al. Improving Patient Safety Through The Involve…
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psnet.ahrq.gov/node/851647/psn-pdf
July 26, 2023 - Statewide perinatal quality improvement, teamwork, and
communication activities in Oklahoma and Texas.
July 26, 2023
Stierman EK, O'Brien BT, Stagg J, et al. Statewide perinatal quality improvement, teamwork, and
communication activities in Oklahoma and Texas. Qual Manag Health Care. 2023;32(3):177-188.
doi:10.109…
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psnet.ahrq.gov/node/844550/psn-pdf
September 01, 2012 - The effect of a Lean quality improvement implementation
program on surgical pathology specimen accessioning
and gross preparation error frequency.
September 1, 2012
Smith ML, Wilkerson T, Grzybicki DM, et al. The effect of a Lean quality improvement implementation
program on surgical pathology specimen accessionin…
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psnet.ahrq.gov/node/34775/psn-pdf
February 07, 2019 - Escape Fire: Lessons for the Future of Health Care.
February 7, 2019
Berwick DM. Washington DC: Commonwealth Fund; 2002.
https://psnet.ahrq.gov/issue/escape-fire-lessons-future-health-care
This report represents an edited version of Donald Berwick’s Plenary Address presented at the Institute for
Healthcare Improve…
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psnet.ahrq.gov/node/73490/psn-pdf
July 14, 2021 - Use of prescribing safety quality improvement reports in
UK general practices: a qualitative assessment.
July 14, 2021
Khan NF, Booth HP, Myles P, et al. Use of prescribing safety quality improvement reports in UK general
practices: a qualitative assessment. BMC Health Serv Res. 2021;21(1). doi:10.1186/s12913-021-0…
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psnet.ahrq.gov/node/37927/psn-pdf
March 10, 2011 - A randomized trial of electronic clinical reminders to
improve medication laboratory monitoring.
March 10, 2011
Matheny ME, Sequist TD, Seger AC, et al. A randomized trial of electronic clinical reminders to improve
medication laboratory monitoring. J Am Med Inform Assoc. 2008;15(4):424-9. doi:10.1197/jamia.M2602.
…
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psnet.ahrq.gov/node/60580/psn-pdf
January 01, 2022 - Sustaining the gains: a 7-year follow-through of a
hospital-wide patient safety improvement project on
hospital-wide adverse event outcomes and patient safety
culture.
June 10, 2020
Sim MA, Ti LK, Mujumdar S, et al. Sustaining the gains: a 7-year follow-through of a hospital-wide patient
safety improvement projec…
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psnet.ahrq.gov/node/35813/psn-pdf
April 06, 2011 - Simulation based teamwork training for emergency
department staff: does it improve clinical team
performance when added to an existing didactic
teamwork curriculum?
April 6, 2011
Shapiro MJ, Morey JC, Small SD, et al. Simulation based teamwork training for emergency department
staff: does it improve clinical team…