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psnet.ahrq.gov/node/837309/psn-pdf
June 01, 2022 - Usability and accessibility of publicly available patient
safety databases.
June 1, 2022
Sheehan JG, Howe JL, Fong A, et al. Usability and accessibility of publicly available patient safety
databases. J Patient Saf. 2022;18(6):565-569. doi:10.1097/pts.0000000000001018.
https://psnet.ahrq.gov/issue/usability-and-ac…
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psnet.ahrq.gov/node/38890/psn-pdf
December 30, 2014 - Intravenous infusion safety technology: return on
investment.
December 30, 2014
Danello SH, Maddox RR, Schaack GJ. Intravenous Infusion Safety Technology: Return on Investment.
Hosp Pharm. 2010;44(8):680-688. doi:10.1310/hpj4408-680.
https://psnet.ahrq.gov/issue/intravenous-infusion-safety-technology-return-invest…
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psnet.ahrq.gov/node/35349/psn-pdf
November 18, 2011 - Leadership Guide to Patient Safety: Resources and Tools
for Establishing and Maintaining Patient Safety.
November 18, 2011
Botwinick L, Bisognano M, Haraden C. Cambridge, MA: Institute for Healthcare Improvement; 2006.
https://psnet.ahrq.gov/issue/leadership-guide-patient-safety-resources-and-tools-establishin…
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psnet.ahrq.gov/node/43371/psn-pdf
June 19, 2019 - Medication Safety Officer's Handbook.
June 19, 2019
Larson CM, Saine D, eds. Bethesda, MD: American Society of Health-System Pharmacists; 2013. ISBN:
9781585282104.
https://psnet.ahrq.gov/issue/medication-safety-officers-handbook
This book provides information about medication errors and quality improvement to gui…
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psnet.ahrq.gov/node/47588/psn-pdf
November 21, 2018 - 2 MSO programs show value of safety position.
November 21, 2018
Wild D. Pharmacy Practice News. November 8, 2018.
https://psnet.ahrq.gov/issue/2-mso-programs-show-value-safety-position
Medication safety officers serve as organizational champions of medication management process
improvement. This news article offer…
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psnet.ahrq.gov/node/42586/psn-pdf
September 11, 2013 - A hazard of impatient medicine.
September 11, 2013
Gunderman R, Lynch J, Harrell H. The Atlantic. September 3, 2013.
https://psnet.ahrq.gov/issue/hazard-impatient-medicine
This magazine article reports on the unique tension between efficiency mandates and patient-centered
care through the example of a cancer patie…
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psnet.ahrq.gov/node/851927/psn-pdf
August 02, 2023 - Perioperative Handoffs.
August 2, 2023
Abraham J, Rosen M, Greilich PE eds. Jt Comm J Qual Patient Saf. 2023;49(8):341-434.
https://psnet.ahrq.gov/issue/perioperative-handoffs
Handoffs occur several times during a surgical procedure, increasing the risk of communication mistakes
and misunderstandings. This special…
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psnet.ahrq.gov/node/73523/psn-pdf
July 21, 2021 - TeamSTEPPS Video Toolkit.
July 21, 2021
AHA Team Training and Project Firstline. Chicago, IL: American Hospital Association, Center for Disease
Control and Prevention; July 2021.
https://psnet.ahrq.gov/issue/teamstepps-video-toolkit
Problems in communication are common contributors to patient care mistakes. This t…
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psnet.ahrq.gov/node/851068/psn-pdf
June 28, 2023 - Building a Culture of Safety in Health Care.
June 28, 2023
Chicago, IL: American Hospital Association: May 2023.
https://psnet.ahrq.gov/issue/building-culture-safety-health-care
Healthcare-acquired infections (HAIs) are a common complication of hospital care. This report summarizes
lessons learned at a series of i…
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psnet.ahrq.gov/node/44503/psn-pdf
November 18, 2024 - Certified Professional in Patient Safety Review Course.
November 18, 2024
Institute for Healthcare Improvement. February 5-6, 2025, 12:00-4:00 PM (eastern).
https://psnet.ahrq.gov/issue/certified-professional-patient-safety-review-course
This online class prepares individuals to apply for the Institute for Healthca…
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psnet.ahrq.gov/node/45311/psn-pdf
May 20, 2019 - The Joint Commission Big Book of Checklists. 2nd
Edition.
May 20, 2019
Oakbrook Terrance, IL: Joint Commission; 2018. ISBN: 9781635850598.
https://psnet.ahrq.gov/issue/joint-commission-big-book-checklists-2nd-edition
Checklists are a widely accepted strategy to improve communication and standardize processes to su…
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psnet.ahrq.gov/node/865348/psn-pdf
January 01, 2023 - Learning Health Systems
January 1, 2023
Agency for Health Research and Quality.
https://psnet.ahrq.gov/issue/learning-health-systems
The learning health system model centers on the purposeful, systematic use of internal data and
knowledge with external evidence to improve the safety and quality of care. This websi…
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psnet.ahrq.gov/node/39182/psn-pdf
May 22, 2019 - ACOG Committee Opinion No. 447: patient safety in
obstetrics and gynecology.
May 22, 2019
Improvement AC of O and GCC on PS and Q. ACOG Committee Opinion No. 447: Patient safety in
obstetrics and gynecology. Obstet Gynecol. 2009;114(6):1424-7. doi:10.1097/AOG.0b013e3181c6f90e.
https://psnet.ahrq.gov/issue/acog-com…
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psnet.ahrq.gov/node/45540/psn-pdf
November 01, 2016 - Performing the wrong procedure.
November 1, 2016
Minnier T, Phrampus P, Waddell L. Performing the Wrong Procedure. JAMA. 2016;316(11):1207-1208.
doi:10.1001/jama.2016.9134.
https://psnet.ahrq.gov/issue/performing-wrong-procedure
Describing an incorrect procedure incident which involved placement of a dialysis cath…
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psnet.ahrq.gov/node/46553/psn-pdf
October 25, 2017 - Telehealth.
October 25, 2017
Tuckson R, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med. 2017;377(16):1585-1592.
doi:10.1056/NEJMsr1503323.
https://psnet.ahrq.gov/issue/telehealth
Telemedicine can improve patient experience and access to health care. This commentary reviews the
current state of telehealth practi…
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psnet.ahrq.gov/node/44678/psn-pdf
July 05, 2017 - Patient Safety Risk Management Playbook.
July 5, 2017
Chicago, IL: American Society for Healthcare Risk Management; 2015.
https://psnet.ahrq.gov/issue/patient-safety-risk-management-playbook
Proactive risk management is an important component to improving the safety of care. Exploring principles
of high reliabilit…
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psnet.ahrq.gov/node/44155/psn-pdf
June 24, 2015 - Patient Safety Tool Kit.
June 24, 2015
WHO Regional Office for the Eastern Mediterranean. Cairo, Egypt: World Health Organization; 2015. ISBN:
9789290220596.
https://psnet.ahrq.gov/issue/patient-safety-tool-kit
Patient safety programs should reflect local needs, motivate clinician and leadership engagement, and
s…
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psnet.ahrq.gov/node/61055/psn-pdf
October 21, 2020 - How administrative burdens can harm health.
October 21, 2020
Herd P, Moynihan D. Health Affairs Health Policy Brief. October 2, 2020.
https://psnet.ahrq.gov/issue/how-administrative-burdens-can-harm-health
The crossover of health equity concepts to patient safety has emerged as a consideration for
improvement. Thi…
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psnet.ahrq.gov/node/60264/psn-pdf
January 14, 2021 - COVID-19 Content. ISMP Medication Safety Alert!
January 14, 2021
March 2020--January 2021.
https://psnet.ahrq.gov/issue/special-editions-covid-19-ismp-medication-safety-alert
Medication safety is improved through the sharing of frontline improvement experiences and concerns.
These articles share recommendations to…
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psnet.ahrq.gov/node/60829/psn-pdf
August 19, 2020 - Patient Safety.
August 19, 2020
Levett-Jones T, ed. Clin Sim Nurs. 2020;44(1):1-78; 2020;45(1):1-60.
https://psnet.ahrq.gov/issue/patient-safety-20
Simulation is a recognized technique to educate and plan to improve care processes and safety. This pair
of special issues highlights the use of simulation in nur…