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psnet.ahrq.gov/node/45926/psn-pdf
May 17, 2017 - Toolkit To Improve Safety in Ambulatory Surgery Centers.
May 17, 2017
Rockville, MD: Agency for Healthcare Research and Quality; December 2014.
https://psnet.ahrq.gov/issue/toolkit-improve-safety-ambulatory-surgery-centers
Ambulatory surgery centers provide care to growing numbers of patients. This toolkit draws fr…
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psnet.ahrq.gov/node/41710/psn-pdf
November 08, 2012 - Improving teamwork on general medical units: when
teams do not work face-to-face.
November 8, 2012
McComb SA, Henneman EA, Hinchey KT, et al. Improving teamwork on general medical units: when teams
do not work face-to-face. Jt Comm J Qual Patient Saf. 2012;38(10):471-478.
https://psnet.ahrq.gov/issue/improving-tea…
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psnet.ahrq.gov/node/39257/psn-pdf
January 27, 2010 - Opportunities and Recommendations for State–Federal
Coordination to Improve Health System Performance: A
Focus on Patient Safety.
January 27, 2010
Buxbaum J. Portland, ME: National Academy for State Health Policy; January 2010.
https://psnet.ahrq.gov/issue/opportunities-and-recommendations-state-federal-coordinati…
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psnet.ahrq.gov/node/60627/psn-pdf
June 24, 2020 - Second opinions improve healthcare outcomes and
reduce costs.
June 24, 2020
Hébert AR. Second opinions improve healthcare outcomes and reduce costs. Employee Benefit News.
2020;June 8.
https://psnet.ahrq.gov/issue/second-opinions-improve-healthcare-outcomes-and-reduce-costs
Second opinions are a strategy for redu…
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psnet.ahrq.gov/node/36117/psn-pdf
July 19, 2006 - A Safer Place for Patients: Learning to Improve Patient
Safety.
July 19, 2006
House of Commons Committee on Public Accounts. London: The Stationery Office Limited; June 2006.
https://psnet.ahrq.gov/issue/safer-place-patients-learning-improve-patient-safety-0
Using data from approximately 974,000 patient safety inc…
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psnet.ahrq.gov/node/37432/psn-pdf
November 29, 2009 - The Pennsylvania Learning Exchange: Helping States
Improve and Integrate Patient Safety
Initiatives—Summary Report.
November 29, 2009
Hanlon C; Rosenthal J. Portland, ME: National Academy for State Health Policy; 2007.
https://psnet.ahrq.gov/issue/pennsylvania-learning-exchange-helping-states-improve-and-integrate…
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psnet.ahrq.gov/node/851926/psn-pdf
August 02, 2023 - Improving Patient Safety Culture – A Practical Guide.
August 2, 2023
London, UK: NHS England; July 2023.
https://psnet.ahrq.gov/issue/improving-patient-safety-culture-practical-guide
A strong patient safety culture needs nurturing to serve as a foundation for launching and sustaining
improvements. This toolkit pro…
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psnet.ahrq.gov/node/50876/psn-pdf
April 22, 2021 - Veterans Accountability Improvement Act.
April 22, 2021
SB 1307, 117th Congress: 2021.
https://psnet.ahrq.gov/issue/veterans-accountability-improvement-act
Reporting clinicians who exhibit practice behaviors that are detrimental to safety is challenged by system
and cultural norms. This legislation aims to strengt…
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psnet.ahrq.gov/node/39915/psn-pdf
December 18, 2014 - Improving the quality of discharge communication with
an educational intervention.
December 18, 2014
Key-Solle M, Paulk E, Bradford K, et al. Improving the quality of discharge communication with an
educational intervention. Pediatrics. 2010;126(4):734-9. doi:10.1542/peds.2010-0884.
https://psnet.ahrq.gov/issue/im…
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psnet.ahrq.gov/node/40999/psn-pdf
January 01, 2012 - Improving patient safety via automated laboratory-based
adverse event grading.
December 15, 2011
Niland JC, Stiller T, Neat J, et al. Improving patient safety via automated laboratory-based adverse event
grading. J Am Med Inform Assoc. 2012;19(1):111-5. doi:10.1136/amiajnl-2011-000513.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/34991/psn-pdf
June 22, 2009 - Use of failure mode and effects analysis in improving the
safety of i.v. drug administration.
June 22, 2009
Adachi W, Lodolce AE. Use of failure mode and effects analysis in improving the safety of i.v. drug
administration. Am J Health Syst Pharm. 2005;62(9):917-20.
https://psnet.ahrq.gov/issue/use-failure-mode-an…
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psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
January 01, 2022 - Spotlight
Spotlight
False Assumptions Result in a Missed
Pneumothorax after Bronchoscopy with
Transbronchial Biopsy
Source and Credits
• This presentation is based on the September 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by:…
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psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
May 01, 2014 - to Benign Prostatic Hyperplasia
August 10, 2019
Remote patient monitoring improves
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psnet.ahrq.gov/issue/creating-learning-health-system-improving-diagnostic-safety-pragmatic-insights-us-health-care
May 12, 2021 - Study
Creating a learning health system for improving diagnostic safety: pragmatic insights from US health care organizations.
Citation Text:
Giardina TD, Shahid U, Mushtaq U, et al. Creating a learning health system for improving diagnostic safety: pragmatic insights from US health care…
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psnet.ahrq.gov/issue/using-lean-improve-medication-administration-safety-search-perfect-dose
September 16, 2015 - Study
Using Lean to improve medication administration safety: in search of the "perfect dose."
Citation Text:
Ching JM, Long C, Williams BL, et al. Using lean to improve medication administration safety: in search of the "perfect dose". Jt Comm J Qual Patient Saf. 2013;39(5):195-204.
C…
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psnet.ahrq.gov/issue/improving-shared-situation-awareness-high-risk-therapies-hospitalized-children
October 20, 2021 - Study
Improving shared situation awareness for high-risk therapies in hospitalized children.
Citation Text:
Sosa T, Mayer B, Chakkalakkal B, et al. Improving shared situation awareness for high-risk therapies in hospitalized children. Hosp Pediatr. 2022;12(1):37-46. doi:10.1542/hpeds.202…
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psnet.ahrq.gov/issue/multiple-component-patient-safety-intervention-english-hospitals-controlled-evaluation-second
February 23, 2011 - Study
Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase.
Citation Text:
Benning A, Dixon-Woods M, Nwulu U, et al. Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase. BMJ. 20…
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psnet.ahrq.gov/issue/efforts-improve-patient-safety-result-13-million-fewer-patient-harms-interim-update-2013
January 07, 2015 - Book/Report
Classic
Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
Citation Text:
Efforts To Improve …
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psnet.ahrq.gov/issue/hospital-testing-effectiveness-co-designed-educational-materials-improve-patient-and-visitor
February 28, 2024 - Study
Hospital testing of the effectiveness of co-designed educational materials to improve patient and visitor knowledge and confidence in reporting patient deterioration.
Citation Text:
King L, Belan I, Clark RA, et al. Hospital testing of the effectiveness of co-designed educational m…
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psnet.ahrq.gov/issue/competencies-improving-diagnosis-interprofessional-framework-education-and-training-health
September 12, 2018 - Study
Competencies for improving diagnosis: an interprofessional framework for education and training in health care.
Citation Text:
Olson A, Rencic J, Cosby K, et al. Competencies for improving diagnosis: an interprofessional framework for education and training in health care. Diagnosi…