-
psnet.ahrq.gov/node/42042/psn-pdf
December 18, 2013 - Finding the patient in patient safety.
December 18, 2013
Hor S-Y, Godbold N, Collier A, et al. Finding the patient in patient safety. Health (London). 2013;17(6):567-
83. doi:10.1177/1363459312472082.
https://psnet.ahrq.gov/issue/finding-patient-patient-safety
Highlighting the value of involving patients in their …
-
psnet.ahrq.gov/node/36428/psn-pdf
December 22, 2010 - Medical errors: where are we now?
December 22, 2010
Mewshaw MR, White KM, Walrath JM. Medical errors: where are we now? Nurs Manage. 2006;37(10):50-
54.
https://psnet.ahrq.gov/issue/medical-errors-where-are-we-now
The authors discuss the Patient Safety and Quality Improvement Act of 2005 and the role nurse manager…
-
psnet.ahrq.gov/node/40572/psn-pdf
June 27, 2018 - Understanding care transitions as a patient safety issue.
June 27, 2018
Butterfield S; Stegel C; Glock S; Tartaglia D.
https://psnet.ahrq.gov/issue/understanding-care-transitions-patient-safety-issue
This article describes a regional collaborative to enhance care transitions of Medicare beneficiaries by
improving …
-
psnet.ahrq.gov/node/39835/psn-pdf
December 27, 2018 - Advancement toward High Reliability in Healthcare
Awards.
December 27, 2018
Department of Defense Patient Safety Program; DoD PSP; DoD
https://psnet.ahrq.gov/issue/advancement-toward-high-reliability-healthcare-awards
This award recognizes outstanding high reliability improvement work in the Military Health System…
-
psnet.ahrq.gov/node/36674/psn-pdf
January 18, 2011 - An intervention to enhance nursing staff teamwork and
engagement.
January 18, 2011
Kalisch BJ, Curley M, Stefanov S. An intervention to enhance nursing staff teamwork and engagement. J
Nurs Adm. 2007;37(2):77-84.
https://psnet.ahrq.gov/issue/intervention-enhance-nursing-staff-teamwork-and-engagement
The authors d…
-
psnet.ahrq.gov/node/38647/psn-pdf
May 20, 2009 - A next act for patient safety.
May 20, 2009
Viola AF, Kallem C, Bronnert J. A next act for patient safety. J AHIMA. 2009;80(4):30-5; quiz 37-8.
https://psnet.ahrq.gov/issue/next-act-patient-safety
This article provides an overview of the Patient Safety and Quality Improvement Act and addresses the
potential roles …
-
psnet.ahrq.gov/node/37360/psn-pdf
January 05, 2012 - Building accountability through patient safety
organizations.
January 5, 2012
Ross J. Building accountability through patient safety organizations. J Perianesth Nurs. 2007;22(5):346-8.
https://psnet.ahrq.gov/issue/building-accountability-through-patient-safety-organizations
This commentary introduces the Patient S…
-
psnet.ahrq.gov/node/39200/psn-pdf
March 28, 2010 - Creating champions for health care quality and safety.
March 28, 2010
Holland R, Meyers D, Hildebrand C, et al. Creating champions for health care quality and safety. Am J Med
Qual. 2010;25(2):102-108. doi:10.1177/1062860609352108.
https://psnet.ahrq.gov/issue/creating-champions-health-care-quality-and-safety
Inte…
-
psnet.ahrq.gov/node/40421/psn-pdf
January 01, 2020 - Safe Surgery 2020.
April 27, 2011
GE Foundation. info@safesurgery2020.org.
https://psnet.ahrq.gov/issue/safe-surgery-2015
This Web site provides programmatic resources building on work to implement the World Health
Organization surgical safety checklist to improve surgical safety worldwide. Its efforts center…
-
psnet.ahrq.gov/node/35041/psn-pdf
January 02, 2017 - AHRQ quality and safety initiatives.
January 2, 2017
Clancy CM. AHRQ quality and safety initiatives. Jt Comm J Qual Patient Saf. 2005;31(6):354-6.
https://psnet.ahrq.gov/issue/ahrq-quality-and-safety-initiatives
Agency for Healthcare Research and Quality (AHRQ) Director Carolyn Clancy briefly presents the
agency's…
-
psnet.ahrq.gov/node/38181/psn-pdf
October 31, 2016 - PSO Privacy Protection Center.
October 31, 2016
Agency for Healthcare Research and Quality; AHRQ.
https://psnet.ahrq.gov/issue/pso-privacy-protection-center
This Web site supports AHRQ implementation of the Patient Safety and Quality Improvement Act of 2005
by providing technical assistance and educational materia…
-
psnet.ahrq.gov/node/42241/psn-pdf
May 01, 2013 - Special Issue on Teamwork.
May 1, 2013
Salas E, Rosen MA, eds. BMJ Qual Saf. 2013;22(5):369-448.
https://psnet.ahrq.gov/issue/special-issue-teamwork
Articles in this special issue explore theory-driven and simulation-based approaches to improve teamwork
in health care.
https://psnet.ahrq.gov/issue/special-…
-
psnet.ahrq.gov/innovation/generalizability-medication-administration-discrepancy-detection-system-quantitative
November 04, 2020 - EMERGING INNOVATIONS
The generalizability of a medication administration discrepancy detection system: quantitative comparative analysis
Citation Text:
Kirkendall E, Huth H, Rauenbuehler B, et al. The generalizability of a medication administration discrepancy detection system: quantitative compar…
-
psnet.ahrq.gov/node/857580/psn-pdf
August 09, 2024 - Patient Safety Research Summaries.
August 9, 2024
Rockville, MD: Agency for Healthcare Research and Quality; 2023-2024.
https://psnet.ahrq.gov/issue/patient-safety-research-summaries
The application of evidence in real situations helps to embed innovation across systems and sustain care
improvement. This col…
-
psnet.ahrq.gov/node/50767/psn-pdf
August 12, 2024 - 2024 IHI Forum
August 12, 2024
Institute for Healthcare Improvement. Orlando World Center Marriott, Orlando, FL, December 9-11, 2024.
https://psnet.ahrq.gov/issue/2024-ihi-forum
This hybrid conference will offer workshops and interactive sessions exploring strategies from within health
care and beyond to improve h…
-
psnet.ahrq.gov/node/42186/psn-pdf
April 24, 2013 - High reliability: truly achieving healthcare quality and
safety.
April 24, 2013
Kaplan GS. Pursuing the perfect patient experience. Front Health Serv Manage. 2013;29(3):16-27.
https://psnet.ahrq.gov/issue/high-reliability-truly-achieving-healthcare-quality-and-safety
This commentary discusses how high reliability …
-
psnet.ahrq.gov/node/50850/psn-pdf
January 29, 2020 - Better Safer Care Victoria.
January 29, 2020
Safer Care Victoria and Victorian Agency for Health Information.
https://psnet.ahrq.gov/issue/better-safer-care-victoria
Large scale tracking of adverse care incidents offers evidence that governments and organizations can use
to target care process improvement efforts.…
-
psnet.ahrq.gov/node/44573/psn-pdf
October 21, 2015 - Getting the diagnosis wrong.
October 21, 2015
Ofri D. New York Times. October 8, 2015.
https://psnet.ahrq.gov/issue/getting-diagnosis-wrong
This news article offers insights from a physician about the complexities around establishing a diagnosis in
frontline practice and the recent IOM report recommendation to imp…
-
psnet.ahrq.gov/node/867769/psn-pdf
March 12, 2025 - Lessons from Event Reports.
March 12, 2025
Lessons from Event Reports. Patient Safety Authority.
https://psnet.ahrq.gov/issue/lessons-event-reports
Small successes can inform and motivate actions leading to sustainable, evidence-based change. This
searchable collection of projects initiated in response to event re…
-
psnet.ahrq.gov/issue/minding-gaps-assessing-communication-outcomes-electronic-preconsultation-exchange
November 30, 2016 - Study
Minding the gaps: assessing communication outcomes of electronic preconsultation exchange.
Citation Text:
Price EL, Sewell JL, Chen AH, et al. Minding the Gaps: Assessing Communication Outcomes of Electronic Preconsultation Exchange. Jt Comm J Qual Patient Saf. 2016;42(8):341-54.
…