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psnet.ahrq.gov/issue/foundations-safety-science
August 07, 2019 - Special or Theme Issue
The Foundations of Safety Science.
Citation Text:
The Foundations of Safety Science. LeCoze JC, Pettersen K, Reiman T, eds. Safety Sci. 2014;67:1-70.
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psnet.ahrq.gov/issue/impact-medical-errors-and-malpractice-health-economics-quality-and-patient-safety
November 28, 2018 - Book/Report
Impact of Medical Errors and Malpractice on Health Economics, Quality, and Patient Safety.
Citation Text:
Impact of Medical Errors and Malpractice on Health Economics, Quality, and Patient Safety. Riga M, ed. Hershey, PA: IGI Global; 2017. ISBN: 9781522523376.
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psnet.ahrq.gov/issue/national-patient-safety-board-act-2022
July 20, 2022 - Legislation/Regulation
National Patient Safety Board Act of 2022.
Citation Text:
National Patient Safety Board Act of 2022. HR 9377, 117th Cong, 2d Sess (2022).
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psnet.ahrq.gov/issue/inequity-and-iatrogenic-harm
August 24, 2022 - Special or Theme Issue
Inequity and Iatrogenic Harm.
Citation Text:
Inequity and Iatrogenic Harm. AMA J Ethics. 2022;24(8):e715-e816.
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psnet.ahrq.gov/issue/advancing-patient-safety-decade-evidence-design-and-implementation
May 07, 2014 - Government Resource
Advancing Patient Safety: A Decade of Evidence, Design, and Implementation.
Citation Text:
Advancing Patient Safety: A Decade of Evidence, Design, and Implementation. Rockville, MD; Agency for Healthcare Research and Quality; November 2009. AHRQ Publication No. 09…
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psnet.ahrq.gov/issue/how-health-care-changes-when-algorithms-start-making-diagnoses
May 29, 2019 - Newspaper/Magazine Article
How health care changes when algorithms start making diagnoses.
Citation Text:
How health care changes when algorithms start making diagnoses. Burt A, Volchenboum S. Harv Bus Rev. May 8, 2018.
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psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued
January 05, 2017 - Discontinued Medications: Are They Really Discontinued?
Citation Text:
Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - One Bronchoscopy, Two Errors
Citation Text:
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. 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/node/50769/psn-pdf
February 15, 2017 - Cultural Competence and Patient Safety
December 27, 2019
Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
Background
Culture can be defined as the “personal identification, language, thoughts, co…
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psnet.ahrq.gov/node/841489/psn-pdf
December 14, 2022 - Rise to Health Coalition.
December 14, 2022
Boston, MA; Institute for Healthcare Improvement: December 2022.
https://psnet.ahrq.gov/issue/rise-health-coalition
Systemic efforts to improve health equity support patient safety. This announcement highlights an initiative
for collective work to address four areas of e…
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psnet.ahrq.gov/node/34699/psn-pdf
January 04, 2017 - Organizational costs of preventable medical errors.
January 4, 2017
Weeks WB, Waldron J, Foster T, et al. The organizational costs of preventable medical errors. Jt Comm J
Qual Improv. 2001;27(10):533-9.
https://psnet.ahrq.gov/issue/organizational-costs-preventable-medical-errors
Using two composite case studies a…
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psnet.ahrq.gov/node/35097/psn-pdf
June 22, 2009 - Impact of duty hour limits on resident training in
otolaryngology.
June 22, 2009
Reiter ER, Wong DR. Impact of duty hour limits on resident training in otolaryngology. Laryngoscope.
2005;115(5):773-9.
https://psnet.ahrq.gov/issue/impact-duty-hour-limits-resident-training-otolaryngology
The authors surveyed reside…
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psnet.ahrq.gov/node/41165/psn-pdf
December 08, 2016 - IHI Open School Patient Safety Curriculum
December 8, 2016
Institute for Healthcare Improvement.
https://psnet.ahrq.gov/issue/patient-safety-curriculum-2nd-edition
There is a documented interest in postgraduate professional education that enables practicing clinicians to
improve the safety of their actions and beh…
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psnet.ahrq.gov/node/42005/psn-pdf
January 30, 2013 - Infusing fun into quality and safety initiatives.
January 30, 2013
Foulk KC, Tocydlowski P, Snow TM, et al. Infusing fun into quality and safety initiatives. Nursing (Brux).
2012;42(11):14-16. doi:10.1097/01.NURSE.0000421386.36112.a9.
https://psnet.ahrq.gov/issue/infusing-fun-quality-and-safety-initiatives
Nursing…
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psnet.ahrq.gov/node/43454/psn-pdf
November 20, 2015 - Training in quality and safety: the current landscape.
November 20, 2015
Karasick AS, Nash DB. Training in quality and safety: the current landscape. Am J Med Qual.
2015;30(6):526-38. doi:10.1177/1062860614544194.
https://psnet.ahrq.gov/issue/training-quality-and-safety-current-landscape
This commentary offers inf…
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psnet.ahrq.gov/node/841198/psn-pdf
December 07, 2022 - Technology, Education and Safety.
December 7, 2022
Arna D, ed. Curr Opin Anaesthesiol. 2022;35(6):710-737.
https://psnet.ahrq.gov/issue/technology-education-and-safety-1
Safety challenges in anesthesiology and perioperative care are high-risk situations. This segment of a
reoccurring special section covers strateg…
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psnet.ahrq.gov/node/42131/psn-pdf
March 20, 2013 - What surgeons leave behind costs some patients dearly.
March 20, 2013
Eisler P.
https://psnet.ahrq.gov/issue/what-surgeons-leave-behind-costs-some-patients-dearly
This newspaper article describes two incidents of retained surgical items and discusses the technological
solutions to prevent them.
https://psnet.ahrq…
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psnet.ahrq.gov/node/45287/psn-pdf
August 03, 2016 - Mistakes We Make in Dialysis.
August 3, 2016
Rodby RA, Perazella MA, eds. Semin Dial. 2016;29(4):253-328.
https://psnet.ahrq.gov/issue/mistakes-we-make-dialysis
Insufficient application of new evidence to inform treatment decisions can hinder safe care delivery. Articles
in this special issue explore common renal …
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psnet.ahrq.gov/node/44583/psn-pdf
February 17, 2016 - Root Cause Analysis Playbook.
February 17, 2016
Chicago, IL: American Society for Healthcare Risk Management; 2015.
https://psnet.ahrq.gov/issue/root-cause-analysis-playbook
Risk management has recently focused on organization-wide improvement in patient safety. This
publication discusses root cause analysis metho…
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psnet.ahrq.gov/node/856639/psn-pdf
November 29, 2023 - Impact Wellbeing.
November 29, 2023
National Institute for Occupational Safety and Health. Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/impact-wellbeing
Clinician burnout has become a major concern for both healthcare workforce and patient safety. This portal
provides access to too…