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psnet.ahrq.gov/node/40317/psn-pdf
November 21, 2016 - Achieving an Exceptional Patient and Family Experience
of Inpatient Hospital Care.
November 21, 2016
Balik B, Conway J, Zipperer L, Watson J. Cambridge, MA: Institute for Healthcare Improvement; 2011.
https://psnet.ahrq.gov/issue/achieving-exceptional-patient-and-family-experience-inpatient-hospital-care
This whit…
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psnet.ahrq.gov/node/865454/psn-pdf
March 27, 2024 - Ensuring Patient and Workforce Safety Culture in
Healthcare
March 27, 2024
Murray J, Sorra J, Gale B, et al. Ensuring Patient and Workforce Safety Culture in Healthcare. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
Introduction
In 2020, the I…
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psnet.ahrq.gov/node/43388/psn-pdf
July 30, 2014 - Exploration of an automated approach for receiving
patient feedback after outpatient acute care visits.
July 30, 2014
Berner ES, Ray MN, Panjamapirom A, et al. Exploration of an automated approach for receiving patient
feedback after outpatient acute care visits. J Gen Intern Med. 2014;29(8):1105-12. doi:10.1007/s1…
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psnet.ahrq.gov/node/42007/psn-pdf
May 23, 2013 - Leaders' and followers' individual experiences during the
early phase of simulation-based team training: an
exploratory study.
May 23, 2013
Meurling L, Hedman L, Felländer-Tsai L, et al. Leaders' and followers' individual experiences during the
early phase of simulation-based team training: an exploratory study. B…
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psnet.ahrq.gov/node/43400/psn-pdf
August 13, 2014 - Readmission after delayed diagnosis of surgical site
infection: a focus on prevention using the American
College of Surgeons National Surgical Quality
Improvement Program.
August 13, 2014
Gibson A, Tevis S, Kennedy G. Readmission after delayed diagnosis of surgical site infection: a focus on
prevention using the …
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psnet.ahrq.gov/node/46277/psn-pdf
August 15, 2017 - Randomized trial of reducing ambulatory malpractice and
safety risk: results of the Massachusetts PROMISES
Project.
August 15, 2017
Schiff G, Nieva HR, Griswold P, et al. Randomized Trial of Reducing Ambulatory Malpractice and Safety
Risk: Results of the Massachusetts PROMISES Project. Med Care. 2017;55(8):797-805…
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psnet.ahrq.gov/node/44471/psn-pdf
September 27, 2016 - Two sides of the safety coin?: how patient engagement
and safety climate jointly affect error occurrence in
hospital units.
September 27, 2016
Schiffinger M, Latzke M, Steyrer J. Two sides of the safety coin?: How patient engagement and safety
climate jointly affect error occurrence in hospital units. Health Care …
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psnet.ahrq.gov/node/46747/psn-pdf
June 06, 2018 - Tackling ambulatory safety risks through patient
engagement: what 10,000 patients and families say about
safety-related knowledge, behaviors, and attitudes after
reading visit notes.
June 6, 2018
Bell SK, Folcarelli P, Fossa A, et al. Tackling Ambulatory Safety Risks Through Patient Engagement: What
10,000 Patien…
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psnet.ahrq.gov/node/43049/psn-pdf
October 31, 2014 - Vital signs: improving antibiotic use among hospitalized
patients.
October 31, 2014
Fridkin SK, Baggs J, Fagan R, et al. Vital signs: improving antibiotic use among hospitalized patients.
MMWR Morb Mortal Wkly Rep. 2014;63(9):194-200.
https://psnet.ahrq.gov/issue/vital-signs-improving-antibiotic-use-among-hospital…
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psnet.ahrq.gov/node/39417/psn-pdf
August 06, 2016 - Safety Culture: Theory, Method and Improvement.
August 6, 2016
Antonsen S. Burlington, VT: Ashgate; 2009. ISBN: 9780754676959.
https://psnet.ahrq.gov/issue/safety-culture-theory-method-and-improvement
This book describes the fundamentals of safety culture in the context of well-known incidents in high-risk
industr…
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psnet.ahrq.gov/node/46576/psn-pdf
October 25, 2017 - Curing our diagnostic disorder.
October 25, 2017
Laposata M. The Pathologist. September 2017;(34):18-27.
https://psnet.ahrq.gov/issue/curing-our-diagnostic-disorder
Diagnostic improvement is gaining recognition as an important goal in health care. This magazine article
reports on one pathologist's efforts to devel…
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psnet.ahrq.gov/node/38423/psn-pdf
September 08, 2010 - Heparin: improving treatment and reducing risk of harm.
September 8, 2010
Daner WE, Gosselin RC, Raschke R, et al. Patient Saf Qual Healthcare. January/February 2009;6:20-25.
https://psnet.ahrq.gov/issue/heparin-improving-treatment-and-reducing-risk-harm
This article explains safety challenges commonly associated w…
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psnet.ahrq.gov/node/39693/psn-pdf
July 21, 2010 - Learning accountability for patient outcomes.
July 21, 2010
Pronovost P. Learning accountability for patient outcomes. JAMA. 2010;304(2):204-5.
doi:10.1001/jama.2010.979.
https://psnet.ahrq.gov/issue/learning-accountability-patient-outcomes
This commentary discusses efforts to reduce central line blood stream infe…
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psnet.ahrq.gov/node/42061/psn-pdf
October 05, 2015 - Preventing Falls in Hospitals: A Toolkit for Improving
Quality of Care.
October 5, 2015
Ganz DA, Huang C, Saliba D, et al. Rockville, MD: Agency for Healthcare Research and Quality; January
2013. AHRQ Publication No. 13-0015-EF.
https://psnet.ahrq.gov/issue/preventing-falls-hospitals-toolkit-improving-quality-care…
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psnet.ahrq.gov/web-mm/dangerous-shift
July 24, 2013 - SPOTLIGHT CASE
Dangerous Shift
Citation Text:
Patterson ES. Dangerous Shift. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
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psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Patient Safety Events Involving Opioid
Dose Stacking
Source and Credits
• This presentation is based on the January 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: Hollie Porras, PharmD, BCPS and Cathy Lammers…
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psnet.ahrq.gov/node/33583/psn-pdf
March 01, 2023 - Simulation Training
March 1, 2023
Edward JJ, Nichols A, Bakerjian D. Simulation Training. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/simulation-training
Originally published in 2014 by researchers at the University of California, San Francisco. Updated in
March 2023, by Jennifer J. Edwards, MS, RN, CHSE…
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psnet.ahrq.gov/node/72689/psn-pdf
January 29, 2021 - But See the Patient First
January 29, 2021
Sinigayan VR. But See the Patient First. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/see-patient-first
The Case
A 55-year-old man with acute myeloid leukemia presented to the emergency department (ED) with a chief
complaint of fever. Five days previously, he …
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psnet.ahrq.gov/node/33823/psn-pdf
January 01, 2017 - Workplace Safety in Health Care
January 1, 2017
Simon RW, Canacari EG. Workplace Safety in Health Care. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/workplace-safety-health-care
Perspective
The patient safety movement has highlighted the risks that patients face when receiving health care. But,
impo…
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psnet.ahrq.gov/node/33682/psn-pdf
April 01, 2009 - In Conversation with...Mark Chassin, MD, MPP, MPH
April 1, 2009
In Conversation with..Mark Chassin, MD, MPP, MPH . PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
Editor's note: Mark R. Chassin, MD, MPP, MPH, is president of The Joint Commission, the preeminent
s…