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psnet.ahrq.gov/node/47589/psn-pdf
January 09, 2019 - Framework for Effective Board Governance of Health
System Quality.
January 9, 2019
Daley Ullem E, Gandhi TK, Mate K, et al. IHI White Paper. Boston, MA: Institute for Healthcare
Improvement; 2018.
https://psnet.ahrq.gov/issue/framework-effective-board-governance-health-system-quality
The role of hospital boards i…
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psnet.ahrq.gov/node/44314/psn-pdf
November 06, 2015 - Unintentional discontinuation of chronic medications for
seniors in nursing homes: evaluation of a national
medication reconciliation accreditation requirement using
a population-based cohort study.
November 6, 2015
Stall NM, Fischer HD, Wu F, et al. Unintentional Discontinuation of Chronic Medications for Seniors…
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psnet.ahrq.gov/node/844989/psn-pdf
February 22, 2023 - Defining and enhancing collaboration between
community pharmacists and primary care providers to
improve medication safety.
February 22, 2023
White A, Fulda KG, Blythe R, et al. Defining and enhancing collaboration between community pharmacists
and primary care providers to improve medication safety. Expert Opin D…
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psnet.ahrq.gov/node/865704/psn-pdf
May 01, 2024 - Supporting error management and safety climate in
ambulatory care practices: the CIRSforte study.
May 1, 2024
Müller BS, Lüttel D, Schütze D, et al. Supporting error management and safety climate in ambulatory care
practices: the CIRSforte study. J Patient Saf. 2024;20(5):314-322. doi:10.1097/pts.0000000000001225.
…
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psnet.ahrq.gov/node/854835/psn-pdf
October 25, 2023 - Improving patient safety by shifting power from health
professionals to patients.
October 25, 2023
BMJ. 2023(383):2219, 2278, 2319, 2331.
https://psnet.ahrq.gov/issue/improving-patient-safety-shifting-power-health-professionals-patients
This compendium of editorials and opinion pieces discuss “Martha’s Rule,” a ne…
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psnet.ahrq.gov/node/50887/psn-pdf
February 12, 2020 - Lessons learned from a systems approach to engaging
patients and families in patient safety transformation.
February 12, 2020
Hatlie MJ, Nahum A, Leonard R, et al. Lessons Learned from a Systems Approach to Engaging Patients
and Families in Patient Safety Transformation. Jt Comm J Qual Patient Saf. 2020;46(3):158-1…
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psnet.ahrq.gov/node/45772/psn-pdf
January 11, 2017 - Technical Series on Safer Primary Care.
January 11, 2017
Geneva, Switzerland: World Health Organization; 2016.
https://psnet.ahrq.gov/issue/technical-series-safer-primary-care
Much of patient safety research has focused on the hospital setting, but a majority of health care is
delivered in the ambulatory setting. …
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psnet.ahrq.gov/node/35588/psn-pdf
February 03, 2011 - Creating a safer health care system: finding the
constraint.
February 3, 2011
Pauker SG, Zane EM, Salem D. Creating a safer health care system: finding the constraint. JAMA.
2005;294(22):2906-8.
https://psnet.ahrq.gov/issue/creating-safer-health-care-system-finding-constraint
This editorial builds on the discussi…
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psnet.ahrq.gov/node/45570/psn-pdf
December 07, 2016 - Getting the Board on Board: What Your Board Needs to
Know About Quality and Safety, Third Edition.
December 7, 2016
Oak Brook, IL; Joint Commission; 2016. ISBN: 9781599409412.
https://psnet.ahrq.gov/issue/getting-board-board-what-your-board-needs-know-about-quality-and-safety-
third-edition
Engaging hospital lead…
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psnet.ahrq.gov/node/837848/psn-pdf
August 17, 2022 - Health care quality and safety in a correctional system:
creating goals and performance measures for
improvement.
August 17, 2022
Neely J, Sampath R, Kirkbride G, et al. Health care quality and safety in a correctional system: creating
goals and performance measures for improvement. J Correct Health Care. 2022;28(…
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psnet.ahrq.gov/node/45943/psn-pdf
March 15, 2017 - Identifying and reducing complications after emergency
room discharge.
March 15, 2017
Hofmann PB, Bagian JP. Patient Saf Qual Healthc. February 20, 2017.
https://psnet.ahrq.gov/issue/identifying-and-reducing-complications-after-emergency-room-discharge
Emergency departments are complex environments that harbor fac…
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psnet.ahrq.gov/node/73065/psn-pdf
March 24, 2021 - Implementing the clinical occurrence reporting and
learning system: a double-loop learning incident
reporting system in long-term care.
March 24, 2021
Goh HS, Tan V, Chang J, et al. Implementing the clinical occurrence reporting and learning system: a
double-loop learning incident reporting system in long-term car…
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psnet.ahrq.gov/node/46844/psn-pdf
March 07, 2018 - Learning collaboratives: insights and a new taxonomy
from AHRQ's two decades of experience.
March 7, 2018
Nix M, McNamara P, Genevro J, et al. Learning Collaboratives: Insights And A New Taxonomy From
AHRQ's Two Decades Of Experience. Health Aff (Millwood). 2018;37(2):205-212.
doi:10.1377/hlthaff.2017.1144.
https…
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psnet.ahrq.gov/node/47568/psn-pdf
March 06, 2019 - Trends in anesthesia-related liability and lessons learned.
March 6, 2019
Mora JC, Kaye AD, Romankowski ML, et al. Trends in Anesthesia-Related Liability and Lessons Learned.
Adv Anesth. 2018;36(1):231-249. doi:10.1016/j.aan.2018.07.009.
https://psnet.ahrq.gov/issue/trends-anesthesia-related-liability-and-lessons-l…
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psnet.ahrq.gov/node/851361/psn-pdf
July 12, 2023 - Types and effects of feedback for emergency ambulance
staff: a systematic mixed studies review and meta-
analysis.
July 12, 2023
Wilson C, Janes G, Lawton R, et al. Types and effects of feedback for emergency ambulance staff: a
systematic mixed studies review and meta-analysis. BMJ Qual Saf. 2023;32(10):573-588.
…
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psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
February 26, 2025 - In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety
Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025
Also Read the Essay
View more articles from the same authors.
Citation Text:
Savitz LA, S…
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psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
February 26, 2025 - Learning Health Systems for Patient Safety
Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Savitz LA, Sousane Z, Mossburg SE. Learning …
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psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - AHRQ PSNet Webinar
AHRQ PSNet Webinar
Making Healthcare Safer (MHS) IV:
Rapid Response Systems and Opioid Stewardship
February 10, 2025
Agenda
2
• Logistics
• Introduction to the Making Healthcare Safer (MHS) IV Reports
• Report 1 – Rapid Response Systems
► Discussion
► PSNet Resources
• Report 2 – Opioi…
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psnet.ahrq.gov/node/846563/psn-pdf
March 21, 2023 - Impact of System Failures on Healthcare Workers
March 21, 2023
Zangaro G, Van CM, Mossburg S. Impact of System Failures on Healthcare Workers . PSNet [internet].
2023.
https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
Introduction
The March 2022 conviction of RaDonda Vaught, a former nu…
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psnet.ahrq.gov/web-mm/too-tight-control
March 20, 2013 - SPOTLIGHT CASE
Too Tight Control
Citation Text:
Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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