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psnet.ahrq.gov/node/47132/psn-pdf
June 28, 2018 - National Steering Committee for Patient Safety.
June 28, 2018
Agency for Healthcare Research and Quality and the Institute for Healthcare Improvement.
https://psnet.ahrq.gov/issue/national-steering-committee-patient-safety
Preventable patient harm is a global public health concern. This announcement highlights a ne…
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psnet.ahrq.gov/node/44718/psn-pdf
November 25, 2015 - Beyond the Quick Fix: Strategies for Improving Patient
Safety.
November 25, 2015
Baker GR. Toronto, ON: Institute of Health Policy, Management and Evaluation, University of Toronto;
2015.
https://psnet.ahrq.gov/issue/beyond-quick-fix-strategies-improving-patient-safety
The 2004 Canadian Adverse Events Study helpe…
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psnet.ahrq.gov/node/42907/psn-pdf
August 02, 2015 - Innovation in safety, and safety in innovation.
August 2, 2015
Eisenberg D, Wren SM. Innovation in safety, and safety in innovation. JAMA Surg. 2014;149(1):7-9.
doi:10.1001/jamasurg.2013.5112.
https://psnet.ahrq.gov/issue/innovation-safety-and-safety-innovation
This commentary discusses systems-focused innovations…
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psnet.ahrq.gov/node/45466/psn-pdf
September 07, 2016 - Building a highway to quality health care.
September 7, 2016
Watson S, Pronovost P. Building a Highway to Quality Health Care. J Patient Saf. 2016;12(3):165-6.
doi:10.1097/PTS.0000000000000074.
https://psnet.ahrq.gov/issue/building-highway-quality-health-care
Substantial progress has been made in improving health …
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psnet.ahrq.gov/node/838639/psn-pdf
October 19, 2022 - Calibrate Dx: A Resource to Improve Diagnostic
Decisions.
October 19, 2022
Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication no. 22(23)-
0047-2-EF.
https://psnet.ahrq.gov/issue/calibrate-dx-resource-improve-diagnostic-decisions
Delayed, wrong, and missed diagnoses are commo…
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psnet.ahrq.gov/node/845352/psn-pdf
September 06, 2023 - Understanding and Improving Diagnostic Safety in
Ambulatory Care.
September 6, 2023
Rockville, MD: Agency for Healthcare Quality and Research; August 22, 2023.
https://psnet.ahrq.gov/issue/understanding-and-improving-diagnostic-safety-ambulatory-care
The articulation of diagnostic error in the ambulatory setting i…
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psnet.ahrq.gov/node/44991/psn-pdf
April 20, 2016 - Does an insulin double-checking procedure improve
patient safety?
April 20, 2016
Modic MB, Albert NM, Sun Z, et al. Does an Insulin Double-Checking Procedure Improve Patient Safety? J
Nurs Adm. 2016;46(3):154-60. doi:10.1097/NNA.0000000000000314.
https://psnet.ahrq.gov/issue/does-insulin-double-checking-procedure-…
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psnet.ahrq.gov/node/73884/psn-pdf
September 29, 2021 - Dual surgeon operating to improve patient safety.
September 29, 2021
Ellis R, Hardie JA, Summerton DJ, et al. Dual surgeon operating to improve patient safety. Surg.
2021;59(7):752-756. doi:10.1016/j.bjoms.2021.02.014.
https://psnet.ahrq.gov/issue/dual-surgeon-operating-improve-patient-safety
Many non-urgent, non-…
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psnet.ahrq.gov/node/34748/psn-pdf
March 07, 2005 - Reducing Adverse Drug Events.
March 7, 2005
Leape LL, Kabcenell A, Berwick DM et al. Boston, MA: Institute for Healthcare Improvement; 1998.
https://psnet.ahrq.gov/issue/reducing-adverse-drug-events
This application-oriented book provides the results of the Institute for Healthcare Improvement (IHI)
Breakthrough S…
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psnet.ahrq.gov/node/38055/psn-pdf
January 12, 2009 - Improving patient safety: patient-focused, high-reliability
team training.
January 12, 2009
McKeon LM, Cunningham PD, Oswaks JSD. Improving patient safety: patient-focused, high-reliability team
training. J Nurs Care Qual. 2009;24(1):76-82. doi:10.1097/NCQ.0b013e31818f5595.
https://psnet.ahrq.gov/issue/improving-p…
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psnet.ahrq.gov/node/50784/psn-pdf
January 08, 2020 - Improving Quality of Care and Patient Outcomes During
Care Transitions (R01).
January 8, 2020
Rockville, MD: Agency for Healthcare Research and Quality; December 6, 2019. PA-20-068.
https://psnet.ahrq.gov/issue/improving-quality-care-and-patient-outcomes-during-care-transitions-r01
Communication during patient tra…
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psnet.ahrq.gov/node/36671/psn-pdf
January 18, 2011 - Increasing vigilance on the medical/surgical floor to
improve patient safety.
January 18, 2011
Jacobs JL, Apatov N, Glei M. Increasing vigilance on the medical/surgical floor to improve patient safety. J
Adv Nurs. 2007;57(5). doi:10.1111/j.1365-2648.2006.04161.x.
https://psnet.ahrq.gov/issue/increasing-vigilance-m…
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psnet.ahrq.gov/node/50568/psn-pdf
October 23, 2019 - Automation of the I-PASS tool to improve transitions of
care.
October 23, 2019
Skaret MM, Weaver TD, Humes RJ, et al. Automation of the I-PASS Tool to Improve Transitions of Care. J
Healthc Qual. 2019;41(5):274-280. doi:10.1097/JHQ.0000000000000174.
https://psnet.ahrq.gov/issue/automation-i-pass-tool-improve-trans…
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psnet.ahrq.gov/node/33780/psn-pdf
July 01, 2015 - Safety and Medical Education
January 1, 2014
Ranji SR. Safety and Medical Education. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/safety-and-medical-education
Annual Perspective 2014
As the patient safety field has grown, so too has the appreciation for the need to improve safety in medical
educatio…
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psnet.ahrq.gov/node/33655/psn-pdf
August 01, 2007 - The PeaceHealth Governance Journey in Support of
Quality and Safety
August 1, 2007
Haughom JL. The PeaceHealth Governance Journey in Support of Quality and Safety. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
Perspective
In recent years, the…
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psnet.ahrq.gov/issue/application-trigger-tool-near-real-time-inform-quality-improvement-activities-prospective
September 26, 2012 - Study
Application of a trigger tool in near real time to inform quality improvement activities: a prospective study in a general medicine ward.
Citation Text:
Wong BM, Dyal S, Etchells E, et al. Application of a trigger tool in near real time to inform quality improvement activities: a p…
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psnet.ahrq.gov/issue/high-reliability-safety-net-hospital-leading-operational-excellence
March 01, 2011 - Study
High reliability in a safety net hospital leading to operational excellence.
Citation Text:
Didion L, Whitfield C, Bishop P, et al. High reliability in a safety net hospital leading to operational excellence. J Patient Saf. 2024;20(5):375-380. doi:10.1097/pts.0000000000001236.
Co…
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psnet.ahrq.gov/issue/incident-reporting-system-does-not-detect-adverse-drug-events-problem-quality-improvement
February 10, 2011 - Study
Classic
Incident reporting system does not detect adverse drug events: a problem for quality improvement.
Citation Text:
Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug events: a problem for quality improvem…
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psnet.ahrq.gov/issue/impact-diagnostic-decision-support-system-consultation-perceptions-gps-and-patients
June 28, 2017 - Study
The impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients.
Citation Text:
Porat T, Delaney B, Kostopoulou O. The impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients. BMC Med Inform Decis M…
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psnet.ahrq.gov/issue/improving-general-practice-computer-systems-patient-safety-qualitative-study-key-stakeholders
October 16, 2012 - Study
Improving general practice computer systems for patient safety: qualitative study of key stakeholders.
Citation Text:
Avery A, Savelyich BSP, Sheikh A, et al. Improving general practice computer systems for patient safety: qualitative study of key stakeholders. Qual Saf Health Ca…