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psnet.ahrq.gov/node/33821/psn-pdf
December 01, 2016 - Errors and Near Misses: What Health Care Could Learn
From Aviation
December 1, 2016
Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
Perspective
Some of the most urg…
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psnet.ahrq.gov/node/33779/psn-pdf
March 01, 2015 - Handoffs and Transitions
January 22, 2014
Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/handoffs-and-transitions
Annual Perspective 2014
Despite recent efforts to promote clinical integration, the United States health care system remains highly
fragmented. From it…
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psnet.ahrq.gov/node/33797/psn-pdf
January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety
Science, Policy, and Practice
January 1, 2016
Singh H. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice. PSNet
[internet]. 2016.
https://psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-prac…
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psnet.ahrq.gov/node/50715/psn-pdf
December 04, 2019 - Quality and Safety of Healthcare in Switzerland.
December 4, 2019
Vincent C, Staines A. Bern, Switzerland: Federal Department of Home Affairs, Federal Office of Public
Health; 2019.
https://psnet.ahrq.gov/issue/quality-and-safety-healthcare-switzerland
Patient safety is a goal for countries worldwide. This report …
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psnet.ahrq.gov/node/44720/psn-pdf
December 16, 2015 - The persistent problem of diagnostic error.
December 16, 2015
Lundberg GD. Medscape. December 1, 2015.
https://psnet.ahrq.gov/issue/persistent-problem-diagnostic-error
Spotlighting the author's experience with autopsies to provide context regarding diagnostic errors as a
patient safety problem, this commentary out…
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psnet.ahrq.gov/node/33593/psn-pdf
June 15, 2024 - Measurement of Patient Safety
June 15, 2024
Measurement of Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/measurement-patient-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient …
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psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-summary
February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary
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February 26, 2025
Innovation
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psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx
Spotlight
When the Lytes Go Out: A Case
of Inpatient Cardiac Arrest
Source and Credits
• This presentation is based on the September 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psne…
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psnet.ahrq.gov/node/866265/psn-pdf
July 31, 2024 - Misplaced Vial: Medication Kit Variability Contributes to
Medication Error During Patient Transport
July 31, 2024
MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During
Patient Transport. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-vial-medicatio…
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psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workforce-challenges
August 30, 2023 - Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges
Kathleen Sanford DBA, RN, FAAN, FACHE; Sue Schuelke PhD, RN-BC, CNE, CCRN-K; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD
| August 30, 2023
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psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
December 15, 2024 - Improving Patient Safety and Team Communication through Daily Huddles
Citation Text:
Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
October 01, 2016 - Health Care Data Science for Quality Improvement and Patient Safety
Alvin Rajkomar, MD | October 1, 2016
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Rajkomar A. Health Care Data Science for Quality Improvement and Patient S…
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psnet.ahrq.gov/issue/improving-emergency-medicine-clinician-awareness-prehospital-administered-medications
October 19, 2022 - Study
Improving emergency medicine clinician awareness of prehospital-administered medications.
Citation Text:
Kamta J, Fregoso B, Lee A, et al. Improving emergency medicine clinician awareness of prehospital-administered medications. Prehosp Emerg Care. 2024;28(3):506-512. doi:10.1080/1…
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psnet.ahrq.gov/issue/improving-usability-safety-and-patient-outcomes-health-information-technology
June 15, 2022 - Special or Theme Issue
Improving Usability, Safety and Patient Outcomes With Health Information Technology.
Citation Text:
Improving Usability, Safety and Patient Outcomes With Health Information Technology. Lau F, Bartle-Clar JA, Bliss G, et al, eds. Stud Health Technol Inform. 2019;257…
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psnet.ahrq.gov/issue/debriefing-improve-interprofessional-teamwork-operating-room-systematic-review
January 31, 2024 - Review
Debriefing to improve interprofessional teamwork in the operating room: a systematic review.
Citation Text:
Skegg E, McElroy C, Mudgway M, et al. Debriefing to improve interprofessional teamwork in the operating room: a systematic review. J Nurs Scholarsh. 2023;55(6):1179-1188. do…
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psnet.ahrq.gov/issue/potential-improved-teamwork-reduce-medical-errors-emergency-department
July 07, 2021 - Review
Classic
The potential for improved teamwork to reduce medical errors in the emergency department.
Citation Text:
Risser DT, Rice MM, Salisbury ML, et al. The potential for improved teamwork to reduce medical errors in the emergency department. Ann Emerg M…
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psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-improve-safety
November 01, 2017 - The Role of Patient-facing Technologies to Empower Patients and Improve Safety
Ronen Rozenblum, MD, MPH, and David Bates, MD, MS | November 1, 2017
Also Read a Conversation
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Citation Text:
Rozenblum R, Bates DW. The Role…
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psnet.ahrq.gov/issue/does-teamwork-improve-performance-operating-room-multilevel-evaluation
July 02, 2014 - Study
Does teamwork improve performance in the operating room? A multilevel evaluation.
Citation Text:
Weaver SJ, Rosen MA, DiazGranados D, et al. Does teamwork improve performance in the operating room? A multilevel evaluation. Jt Comm J Qual Patient Saf. 2010;36(3):133-42.
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psnet.ahrq.gov/issue/compliance-who-surgical-safety-checklist-deviations-and-possible-improvements
September 29, 2017 - Study
Compliance with the WHO Surgical Safety Checklist: deviations and possible improvements.
Citation Text:
Rydenfält C, Johansson G, Odenrick P, et al. Compliance with the WHO Surgical Safety Checklist: deviations and possible improvements. Int J Qual Health Care. 2013;25(2):182-187. …
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psnet.ahrq.gov/issue/improving-care-transitions-current-practice-and-future-opportunities-pharmacists
December 12, 2012 - Commentary
Improving care transitions: current practice and future opportunities for pharmacists.
Citation Text:
Pharmacy AC of C, Hume AL, Kirwin J, et al. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012;32(11):e326-37. doi…