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psnet.ahrq.gov/node/38485/psn-pdf
June 23, 2017 - Impact of a comprehensive patient safety strategy on
obstetric adverse events.
June 23, 2017
Pettker CM, Thung SF, Norwitz ER, et al. Impact of a comprehensive patient safety strategy on obstetric
adverse events. Am J Obstet Gynecol. 2009;200(5):492.e1-8. doi:10.1016/j.ajog.2009.01.022.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/50865/psn-pdf
February 05, 2020 - Understanding principles of high reliability organizations
through the eyes of VIONE: a clinical program to improve
patient safety by deprescribing potentially inappropriate
medications and reducing polypharmacy.
February 5, 2020
Battar S, Dickerson KRW, Sedgwick C, et al. Understanding principles of high reliabil…
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psnet.ahrq.gov/node/857455/psn-pdf
January 01, 2024 - Addressing veteran health-related social needs: how
Joint Commission standards accelerated integration and
expansion of tools and services in the Veterans Health
Administration.
December 6, 2023
List JM, Russell LE, Hausmann LRM, et al. Addressing veteran health-related social needs: how Joint
Commission standard…
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psnet.ahrq.gov/node/867596/psn-pdf
January 22, 2025 - Creation of root cause analysis and action (RCA2)
standard work by a multidisciplinary team to prevent
harm, reduce bias, and improve safety culture.
January 22, 2025
Musheno D, Harnish M, Roberts J, et al. Creation of root cause analysis and action (RCA2) standard work
by a multidisciplinary team to prevent harm,…
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psnet.ahrq.gov/node/72748/psn-pdf
February 17, 2021 - The Collective Leadership for Safety Culture (Co-Lead)
team intervention to promote teamwork and patient
safety.
February 17, 2021
De Brún A, Anjara S, Cunningham U, et al. The Collective Leadership for Safety Culture (Co-Lead) team
intervention to promote teamwork and patient safety. Int J Environ Res Public Heal…
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psnet.ahrq.gov/node/865678/psn-pdf
April 24, 2024 - Enhancing implementation of the I-PASS handoff tool
using a provider handoff task force at a Comprehensive
Cancer Center.
April 24, 2024
Franco Vega MC, Ait Aiss M, George M, et al. Enhancing implementation of the I-PASS handoff tool using
a provider handoff task force at a Comprehensive Cancer Center. Jt Comm J Q…
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psnet.ahrq.gov/node/40394/psn-pdf
January 01, 2019 - Partnership for Patients.
October 6, 2016
Washington, DC: US Department of Health and Human Services.
https://psnet.ahrq.gov/issue/partnership-patients
Launched in 2011, the Partnership for Patients plans to invest approximately $1 billion total in an effort to
decrease preventable harm in United States hospitals.…
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psnet.ahrq.gov/node/850340/psn-pdf
June 14, 2023 - Assertive communication training for nurses to speak up
in cases of medical errors: a systematic review and meta-
analysis.
June 14, 2023
Chen H-W, Wu J-C, Kang Y-N, et al. Assertive communication training for nurses to speak up in cases of
medical errors: a systematic review and meta-analysis. Nurse Educ Today. 2…
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psnet.ahrq.gov/node/40260/psn-pdf
February 08, 2017 - A case for safety leadership team training of hospital
managers.
February 8, 2017
Singer SJ, Hayes J, Cooper JB, et al. A case for safety leadership team training of hospital managers.
Health Care Manage Rev. 2011;36(2):188-200. doi:10.1097/HMR.0b013e318208cd1d.
https://psnet.ahrq.gov/issue/case-safety-leadership-…
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psnet.ahrq.gov/node/60051/psn-pdf
March 18, 2020 - Enhancing teamwork communication and patient safety
responsiveness in a paediatric intensive care unit using
the daily safety huddle tool.
March 18, 2020
Aldawood F, Kazzaz Y, AlShehri A, et al. Enhancing teamwork communication and patient safety
responsiveness in a paediatric intensive care unit using the daily s…
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psnet.ahrq.gov/node/40994/psn-pdf
December 18, 2014 - Implementing medication reconciliation in outpatient
pediatrics.
December 18, 2014
Rappaport DI, Collins B, Koster A, et al. Implementing medication reconciliation in outpatient pediatrics.
Pediatrics. 2011;128(6):e1600-7. doi:10.1542/peds.2011-0993.
https://psnet.ahrq.gov/issue/implementing-medication-reconciliat…
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psnet.ahrq.gov/node/47867/psn-pdf
June 19, 2019 - Increasing compliance of safe medication administration
in pediatric anesthesia by use of a standardized checklist.
June 19, 2019
Kanjia MK, Adler AC, Buck D, et al. Increasing compliance of safe medication administration in pediatric
anesthesia by use of a standardized checklist. Paediatr Anaesth. 2019;29(3):258-2…
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psnet.ahrq.gov/node/44552/psn-pdf
June 21, 2016 - Reducing diagnostic errors—why now?
June 21, 2016
Khullar D, Jha AK, Jena AB. Reducing diagnostic errors--why now? N Engl J Med. 2015;373(26):2491-
2493. doi:10.1056/NEJMp1508044.
https://psnet.ahrq.gov/issue/reducing-diagnostic-errors-why-now
Diagnostic error has recently garnered attention as a patient safety pr…
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psnet.ahrq.gov/node/44776/psn-pdf
April 15, 2016 - Best practices for chemotherapy administration in
pediatric oncology: quality and safety process
improvements (2015).
April 15, 2016
Looper K, Winchester K, Robinson D, et al. Best Practices for Chemotherapy Administration in Pediatric
Oncology: Quality and Safety Process Improvements (2015). J Pediatr Oncol Nurs.…
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psnet.ahrq.gov/node/47962/psn-pdf
May 01, 2019 - Understanding the clinical implications of resident
involvement in uncommon operations.
May 1, 2019
Dasani SS, Simmons KD, Wirtalla CJ, et al. Understanding the Clinical Implications of Resident
Involvement in Uncommon Operations. J Surg Educ. 2019;76(5):1319-1328.
doi:10.1016/j.jsurg.2019.03.011.
https://psnet.a…
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psnet.ahrq.gov/node/858162/psn-pdf
January 01, 2024 - Assessing the clinical, economic, and health resource
utilization impacts of prefilled syringes versus
conventional medication administration methods: results
from a systematic literature review.
December 13, 2023
Benhamou D, Weiss M, Borms M, et al. Assessing the clinical, economic, and health resource utilizatio…
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psnet.ahrq.gov/node/47059/psn-pdf
May 16, 2018 - Participating in a multisite study exploring operational
failures encountered by frontline nurses: lessons learned.
May 16, 2018
Melnyk H, Rosenfeld P, Glassman KS. Participating in a Multisite Study Exploring Operational Failures
Encountered by Frontline Nurses: Lessons Learned. J Nurs Adm. 2018;48(4):203-208.
do…
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psnet.ahrq.gov/node/35462/psn-pdf
February 18, 2011 - Effect of the transformation of the Veterans Affairs Health
Care System on the quality of care.
February 18, 2011
Jha AK, Perlin JB, Kizer KW, et al. Effect of the transformation of the Veterans Affairs Health Care System
on the quality of care. N Engl J Med. 2003;348(22):2218-27.
https://psnet.ahrq.gov/issue/effe…
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psnet.ahrq.gov/node/46794/psn-pdf
May 17, 2018 - Implementation of diagnostic pauses in the ambulatory
setting.
May 17, 2018
Huang GC, Kriegel G, Wheaton C, et al. Implementation of diagnostic pauses in the ambulatory setting.
BMJ Qual Saf. 2018;27(6):492-497. doi:10.1136/bmjqs-2017-007192.
https://psnet.ahrq.gov/issue/implementation-diagnostic-pauses-ambulatory…
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psnet.ahrq.gov/node/867229/psn-pdf
January 01, 2025 - Feasibility of prospective error reporting in home
palliative care: a mixed methods study.
December 4, 2024
Kurahashi AM, Kim G, Parry N, et al. Feasibility of prospective error reporting in home palliative care: a
mixed methods study. Palliat Med. 2025;39(1):22-30. doi:10.1177/02692163241288774.
https://psnet.ahr…