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psnet.ahrq.gov/node/43258/psn-pdf
May 01, 2015 - Interventions employed to improve intrahospital
handover: a systematic review.
May 1, 2015
Robertson ER, Morgan L, Bird S, et al. Interventions employed to improve intrahospital handover: a
systematic review. BMJ Qual Saf. 2014;23(7):600-7. doi:10.1136/bmjqs-2013-002309.
https://psnet.ahrq.gov/issue/interventions-…
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psnet.ahrq.gov/node/72719/psn-pdf
February 10, 2021 - The Diagnostic Error Index: a quality improvement
initiative to identify and measure diagnostic errors.
February 10, 2021
Perry MF, Melvin JE, Kasick RT, et al. The Diagnostic Error Index: a quality improvement initiative to
identify and measure diagnostic errors. J Pediatr. 2021;232:257-263. doi:10.1016/j.jpeds.20…
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psnet.ahrq.gov/node/840484/psn-pdf
November 30, 2022 - Interdisciplinary collaboration across secondary and
primary care to improve medication safety in the elderly
(The IMMENSE study) - a randomized controlled trial.
November 30, 2022
Johansen JS, Halvorsen KH, Svendsen K, et al. Interdisciplinary collaboration across secondary and
primary care to improve medication …
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psnet.ahrq.gov/node/35853/psn-pdf
May 20, 2015 - What practices will most improve safety? Evidence-based
medicine meets patient safety.
May 20, 2015
Leape L, Berwick DM, Bates DW. What practices will most improve safety? Evidence-based medicine
meets patient safety. JAMA. 2002;288(4):501-7.
https://psnet.ahrq.gov/issue/what-practices-will-most-improve-safety-evi…
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psnet.ahrq.gov/node/867013/psn-pdf
October 23, 2024 - Reducing automated dispensing cabinet overrides in the
peri-anesthesia care unit: a quality improvement project.
October 23, 2024
Franciscovich CD, Bieniek A, Dunn K, et al. Reducing automated dispensing cabinet overrides in the peri-
anesthesia care unit: a quality improvement project. Jt Comm J Qual Patient Saf. …
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psnet.ahrq.gov/node/41726/psn-pdf
September 26, 2012 - Improving America's Hospitals: The Joint Commission's
Annual Report on Quality and Safety 2012.
September 26, 2012
Oakbrook Terrace, IL: The Joint Commission; September 2012.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-
safety-2012
The seventh annual Joint…
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psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - The Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis
Introduction
Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
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psnet.ahrq.gov/issue/patient-safety-obstetrics-and-gynecology-improving-outcomes-reducing-risks
May 29, 2019 - Special or Theme Issue
Patient Safety in Obstetrics and Gynecology: Improving Outcomes, Reducing Risks.
Citation Text:
Patient Safety in Obstetrics and Gynecology: Improving Outcomes, Reducing Risks. Gluck PA, ed. Obstet Gynecol Clin. 2008;35(1):1-168.
Copy Citation
…
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psnet.ahrq.gov/node/33759/psn-pdf
October 01, 2012 - Promising Areas for Patient Safety Research
December 1, 2003
Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. PSNet [internet]. 2003.
https://psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
Perspective
Setting a Course for Patient Safety Research
Although patient safety…
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psnet.ahrq.gov/node/60810/psn-pdf
August 12, 2020 - Hospitals Can Take Key Steps to Improve Safe Use of
Digital Systems.
August 12, 2020
Philadelphia, PA: Pew Charitable Trusts; July 21, 2020.
https://psnet.ahrq.gov/issue/hospitals-can-take-key-steps-improve-safe-use-digital-systems
Tracking problems with health information technology (Health IT) is an important st…
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psnet.ahrq.gov/node/37594/psn-pdf
September 24, 2010 - Improving sepsis care through systems change: the
impact of a medical emergency team.
September 24, 2010
Sarani B, Brenner SR, Gabel B, et al. Improving sepsis care through systems change: the impact of a
medical emergency team. Jt Comm J Qual Patient Saf. 2008;34(3):179-182, 125.
https://psnet.ahrq.gov/issue/impr…
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psnet.ahrq.gov/node/39085/psn-pdf
November 11, 2009 - Integrating ethics and patient safety: the role of clinical
ethics consultants in quality improvement.
November 11, 2009
Opel DJ, Brownstein D, Diekema DS, et al. Integrating ethics and patient safety: the role of clinical ethics
consultants in quality improvement. J Clin Ethics. 2009;20(3):220-6.
https://psnet.ah…
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psnet.ahrq.gov/node/38913/psn-pdf
May 24, 2015 - Thinking Outside the Pillbox: A System-wide Approach to
Improving Patient Medication Adherence for Chronic
Disease.
May 24, 2015
Cambridge, MA: New England Healthcare Institute; August 12, 2009.
https://psnet.ahrq.gov/issue/thinking-outside-pillbox-system-wide-approach-improving-patient-medication-
adherence-chro…
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psnet.ahrq.gov/node/36811/psn-pdf
August 26, 2011 - Expanded surgical time out: a key to real-time data
collection and quality improvement.
August 26, 2011
Altpeter T, Luckhardt K, Lewis JN, et al. Expanded surgical time out: a key to real-time data collection and
quality improvement. J Am Coll Surg. 2007;204(4):527-32.
https://psnet.ahrq.gov/issue/expanded-surgica…
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psnet.ahrq.gov/node/36331/psn-pdf
October 26, 2010 - Using system analysis to build a safety culture: improving
the reliability of epidural analgesia.
October 26, 2010
Garnerin P, Huchet-Belouard A, Diby M, et al. Using system analysis to build a safety culture: improving
the reliability of epidural analgesia. Acta Anaesthesiol Scand. 2006;50(9):1114-9.
https://psne…
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psnet.ahrq.gov/node/37497/psn-pdf
February 15, 2011 - Reporting medical errors to improve patient safety: a
survey of physicians in teaching hospitals.
February 15, 2011
Kaldjian LC, Jones EW, Wu BJ, et al. Reporting medical errors to improve patient safety: a survey of
physicians in teaching hospitals. Arch Intern Med. 2008;168(1):40-6. doi:10.1001/archinternmed.2007…
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psnet.ahrq.gov/node/44487/psn-pdf
September 23, 2015 - Patient safety and quality improvement: terminology.
September 23, 2015
Pereira-Argenziano L, Levy FH. Patient Safety and Quality Improvement: Terminology. Pediatr Rev.
2015;36(9):403-11; quiz 412-3. doi:10.1542/pir.36-9-403.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-terminology
To Err Is…
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psnet.ahrq.gov/node/41213/psn-pdf
September 20, 2012 - A resident-led institutional patient safety and quality
improvement process.
September 20, 2012
Stueven J, Sklar DP, Kaloostian P, et al. A resident-led institutional patient safety and quality improvement
process. Am J Med Qual. 2012;27(5):369-76. doi:10.1177/1062860611429387.
https://psnet.ahrq.gov/issue/residen…
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psnet.ahrq.gov/node/72688/psn-pdf
October 06, 2022 - Request for proposals for clinical quality measures to
improve diagnosis.
October 6, 2022
Palo Alto CA; Gordon and Betty Moore Foundation: February 22, 2022.
https://psnet.ahrq.gov/issue/request-proposals-clinical-quality-measures-improve-diagnosis
A lack of consensus on measures for the effectiveness and ac…
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psnet.ahrq.gov/node/41755/psn-pdf
October 10, 2012 - Utah Tenth Anniversary (2001–2011) Patient Safety
Report: Identifying Opportunities for Improvement.
October 10, 2012
Salt Lake City, UT: Utah Department of Health, HealthInsight, Utah Hospital Association; 2012.
https://psnet.ahrq.gov/issue/utah-tenth-anniversary-2001-2011-patient-safety-report-identifying-
oppor…