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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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. …
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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. …
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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(…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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. …
  16. 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…
  17. 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 …
  18. AHRQ PSNet Webinar (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…

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