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psnet.ahrq.gov/issue/economic-evaluation-quality-improvement-interventions-bloodstream-infections-related-central
March 30, 2022 - Review
Economic evaluation of quality improvement interventions for bloodstream infections related to central catheters: a systematic review.
Citation Text:
Nuckols TK, Keeler E, Morton SC, et al. Economic Evaluation of Quality Improvement Interventions for Bloodstream Infections Related…
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psnet.ahrq.gov/issue/scaling-diagnostic-pause-icu-ward-transition-exploration-barriers-and-facilitators
July 19, 2019 - Study
Scaling up a diagnostic pause at the ICU-to-ward transition: an exploration of barriers and facilitators to implementation of the ICU-PAUSE handoff tool.
Citation Text:
Cornell EG, Harris E, McCune E, et al. Scaling up a diagnostic pause at the ICU-to-ward transition: an exploratio…
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psnet.ahrq.gov/issue/preventing-catheter-associated-bloodstream-infections-survey-policies-insertion-and-care
June 14, 2023 - Study
Preventing catheter-associated bloodstream infections: a survey of policies for insertion and care of central venous catheters from hospitals in the Prevention Epicenter Program.
Citation Text:
Warren DK, Yokoe D, Climo MW, et al. Preventing catheter-associated bloodstream infect…
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psnet.ahrq.gov/issue/observer-based-tools-non-technical-skills-assessment-simulated-and-real-clinical-environments
September 02, 2015 - Review
Emerging Classic
Observer-based tools for non-technical skills assessment in simulated and real clinical environments in healthcare: a systematic review.
Citation Text:
Higham H, Greig PR, Rutherford J, et al. Observer-based tools for non-technical skills…
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psnet.ahrq.gov/issue/using-human-factors-and-ergonomics-principles-prevent-inpatient-falls
November 09, 2022 - Study
Using human factors and ergonomics principles to prevent inpatient falls.
Citation Text:
Kwok Y-ting, Lam M-sang. Using human factors and ergonomics principles to prevent inpatient falls. BMJ Open Qual. 2022;11(1):e001696. doi:10.1136/bmjoq-2021-001696.
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psnet.ahrq.gov/issue/examining-patient-safety-events-using-behaviour-change-wheel-cross-sectional-analysis
September 20, 2012 - Study
Examining patient safety events using the behaviour change wheel: a cross-sectional analysis.
Citation Text:
Somerville M, Cassidy C, MacPhee S, et al. Examining patient safety events using the behaviour change wheel: a cross-sectional analysis. Jt Comm J Qual Patient Saf. 2025;51(…
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psnet.ahrq.gov/issue/governing-patient-safety-lessons-learned-mixed-methods-evaluation-implementing-ward-level
June 25, 2014 - Study
Governing patient safety: lessons learned from a mixed methods evaluation of implementing a ward-level medication safety scorecard in two English NHS hospitals.
Citation Text:
Ramsay AIG, Turner S, Cavell G, et al. Governing patient safety: lessons learned from a mixed methods ev…
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psnet.ahrq.gov/issue/simulation-debriefing-enhanced-needs-assessment-address-quality-markers-health-care
June 22, 2022 - Study
Simulation-debriefing enhanced needs assessment to address quality markers in health care: an innovation for prospective hazard analysis.
Citation Text:
Barker LT, Bond WF, Willemsen-Dunlap AM, et al. Simulation-debriefing enhanced needs assessment to address quality markers in hea…
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psnet.ahrq.gov/issue/electronic-health-record-related-safety-concerns-cross-sectional-survey
August 03, 2016 - Study
Electronic health record–related safety concerns: a cross-sectional survey.
Citation Text:
Menon S, Singh H, Meyer AND, et al. Electronic health record-related safety concerns: a cross-sectional survey. J Healthc Risk Manag. 2014;34(1):14-26. doi:10.1002/jhrm.21146.
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psnet.ahrq.gov/issue/impact-inpatient-electronic-prescribing-system-prescribing-error-causation-qualitative
February 16, 2022 - Study
Impact of an inpatient electronic prescribing system on prescribing error causation: a qualitative evaluation in an English hospital.
Citation Text:
Puaar SJ, Franklin BD. Impact of an inpatient electronic prescribing system on prescribing error causation: a qualitative evaluation …
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psnet.ahrq.gov/issue/can-aviation-based-team-training-elicit-sustainable-behavioral-change
July 19, 2023 - Study
Can aviation-based team training elicit sustainable behavioral change?
Citation Text:
Sax HC, Browne P, Mayewski RJ, et al. Can aviation-based team training elicit sustainable behavioral change? Arch Surg. 2009;144(12):1133-1137. doi:10.1001/archsurg.2009.207.
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psnet.ahrq.gov/issue/intervention-reduce-transmission-resistant-bacteria-intensive-care
February 29, 2012 - Study
Classic
Intervention to reduce transmission of resistant bacteria in intensive care.
Citation Text:
Huskins C, Huckabee CM, O'Grady NP, et al. Intervention to reduce transmission of resistant bacteria in intensive care. N Engl J Med. 2011;364(15):1407-18…
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psnet.ahrq.gov/issue/characterising-nature-primary-care-patient-safety-incident-reports-england-and-wales-national
December 16, 2015 - Book/Report
Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice.
Citation Text:
Carson-Stevens A, Hibbert P, Williams H, et al. Characterising …
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psnet.ahrq.gov/issue/lifetime-prevalence-and-correlates-patient-perceived-medical-errors-experienced-us-ambulatory
June 09, 2021 - Study
Lifetime prevalence and correlates of patient-perceived medical errors experienced in the U.S. ambulatory setting: a population-based study.
Citation Text:
Sundwall DN, Munger MA, Tak CR, et al. Lifetime prevalence and correlates of patient-perceived medical errors experienced in t…
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psnet.ahrq.gov/issue/inadequate-hand-communication
April 02, 2015 - Sentinel Event Alerts
Inadequate hand-off communication.
Citation Text:
Inadequate hand-off communication. Sentinel event alert. 2017;58(58):1-6.
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psnet.ahrq.gov/issue/eliminating-central-line-associated-bloodstream-infections-national-patient-safety-imperative
March 21, 2012 - Study
Eliminating central line-associated bloodstream infections: a national patient safety imperative.
Citation Text:
Berenholtz SM, Lubomski LH, Weeks K, et al. Eliminating central line-associated bloodstream infections: a national patient safety imperative. Infect Control Hosp Epidem…
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psnet.ahrq.gov/issue/impact-interoperability-smart-infusion-pumps-and-electronic-medical-record-critical-care
August 25, 2021 - Study
Impact of interoperability of smart infusion pumps and an electronic medical record in critical care.
Citation Text:
Joseph R, Lee SW, Anderson SV, et al. Impact of interoperability of smart infusion pumps and an electronic medical record in critical care. Am J Health-System Pharm.…
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psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle
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January 01, 2015 - In Conversation With… Mark Graban, MS, MBA
January 1, 2015
In Conversation With… Mark Graban, MS, MBA. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
Editor's note: Mark Graban, MS, MBA, is an internationally recognized expert in Lean Healthcare, which
has become one of…
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psnet.ahrq.gov/node/33939/psn-pdf
January 17, 2012 - VHA National Patient Safety Improvement Handbook.
January 17, 2012
https://psnet.ahrq.gov/issue/vha-national-patient-safety-improvement-handbook
A handbook developed by the VA and the National Center for Patient Safety that provides guidance on how
to limit opportunities that adversely impact patient safety and car…