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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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 …
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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-…
  8. Psn-Pdf (pdf file)

    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-…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. 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…
  17. 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…
  18. 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…
  19. 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…
  20. 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…

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