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psnet.ahrq.gov/issue/distractions-interruptions-and-patient-safety
February 01, 2014 - Commentary
Distractions, interruptions, and patient safety.
Citation Text:
Beyea SC. Distractions, interruptions, and patient safety. AORN J. 2007;86(1):109-12.
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psnet.ahrq.gov/issue/building-safety-culture
December 21, 2014 - Commentary
Building a safety culture.
Citation Text:
Milligan F, Dennis S. Building a safety culture. Nurs Stand. 2005;20(11):48-52.
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psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
January 01, 2015 - Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care
Paul E. Plsek, MS | January 1, 2015
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Plsek PE. Innovation and Lean Thinking: Mutuall…
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psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
August 05, 2022 - Duplicate Therapies in Retail Pharmacy
Citation Text:
Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/triple-handoff
March 01, 2004 - SPOTLIGHT CASE
Triple Handoff
Citation Text:
Vidyarthi A. Triple Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
October 28, 2020 - SPOTLIGHT CASE
Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis
Citation Text:
Kuye I, Rhee C. Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/primer/opioid-safety
December 15, 2024 - Opioid Safety
Citation Text:
Opioid Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/perspective/maternal-safety
January 01, 2015 - Annual Perspective
Maternal Safety
Audrey Lyndon, RN, PhD | December 22, 2018
View more articles from the same authors.
Citation Text:
Lyndon A. Maternal Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of H…
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psnet.ahrq.gov/node/33565/psn-pdf
September 01, 2024 - Healthcare-associated Infections
June 15, 2024
Healthcare - Associated Infections. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/health-care-associated-infections
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice …
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psnet.ahrq.gov/node/867845/psn-pdf
February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step
Technique Innovation Summary
February 26, 2025
https://psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-
summary
Summary
This innovation describes the Veteran Health Administration (VHA) National Center for Patient Saf…
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psnet.ahrq.gov/node/33715/psn-pdf
July 01, 2011 - Becoming a Patient Safety Organization
July 1, 2011
Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/becoming-patient-safety-organization
Perspective
While I was the first employee of the California Hospital Patient Safety Organization (CHPSO), its story
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psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
March 01, 2007 - The Soil, Not the Seed: The Real Problem with Root Cause Analysis
Patrice Spath, BA, RHIT, and William Minogue, MD | July 1, 2008
View more articles from the same authors.
Citation Text:
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause …
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psnet.ahrq.gov/node/47560/psn-pdf
January 09, 2019 - Scaling safety: the South Carolina Surgical Safety
Checklist experience.
January 9, 2019
Berry WR, Edmondson L, Gibbons LR, et al. Scaling Safety: The South Carolina Surgical Safety Checklist
Experience. Health Aff (Millwood). 2018;37(11):1779-1786. doi:10.1377/hlthaff.2018.0717.
https://psnet.ahrq.gov/issue/scali…
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psnet.ahrq.gov/node/844766/psn-pdf
January 01, 2020 - Validation of new ICD-10-based patient safety indicators
for identification of in-hospital complications in surgical
patients: a study of diagnostic accuracy.
September 11, 2019
McIsaac DI, Hamilton GM, Abdulla K, et al. Validation of new ICD-10-based patient safety indicators for
identification of in-hospital com…
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psnet.ahrq.gov/node/37771/psn-pdf
June 29, 2011 - Effect of crew resource management training in a
multidisciplinary obstetrical setting.
June 29, 2011
Haller G, Garnerin P, Morales M-A, et al. Effect of crew resource management training in a multidisciplinary
obstetrical setting. Int J Qual Health Care. 2008;20(4):254-63. doi:10.1093/intqhc/mzn018.
https://psnet…
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psnet.ahrq.gov/node/41983/psn-pdf
January 16, 2013 - A systematic review of evidence on the links between
patient experience and clinical safety and effectiveness.
January 16, 2013
Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and
clinical safety and effectiveness. BMJ Open. 2013;3(1). doi:10.1136/bmjopen-2012-0015…
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psnet.ahrq.gov/node/41986/psn-pdf
January 23, 2013 - Slow progress on meeting hospital safety standards:
learning from the Leapfrog Group's efforts.
January 23, 2013
Moran J, Scanlon D. Slow progress on meeting hospital safety standards: learning from the Leapfrog
Group's efforts. Health Aff (Millwood). 2013;32(1):27-35. doi:10.1377/hlthaff.2011.0056.
https://psnet.…
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psnet.ahrq.gov/node/39210/psn-pdf
January 12, 2010 - Can aviation-based team training elicit sustainable
behavioral change?
January 12, 2010
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.
https://psnet.ahrq.gov/issue/can-aviation-based-team…
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psnet.ahrq.gov/node/41813/psn-pdf
July 02, 2014 - The effects of patient handoff characteristics on
subsequent care: a systematic review and areas for future
research.
July 2, 2014
Foster S, Manser T. The effects of patient handoff characteristics on subsequent care: a systematic review
and areas for future research. Acad Med. 2012;87(8):1105-24. doi:10.1097/ACM.…
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psnet.ahrq.gov/node/47733/psn-pdf
April 27, 2019 - Impact of the Agency for Healthcare Research and
Quality's Safety Program for Perinatal Care.
April 27, 2019
Kahwati LC, Sorensen A, Teixeira-Poit S, et al. Impact of the Agency for Healthcare Research and
Quality's Safety Program for Perinatal Care. Jt Comm J Qual Patient Saf. 2019;45(4):231-240.
doi:10.1016/j.jc…