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psnet.ahrq.gov/node/839328/psn-pdf
November 02, 2022 - Quality and Safety.
November 2, 2022
Iyer R, Walker A, eds. Paediatr Anaesth. 2022;32(11):1176-1272.
https://psnet.ahrq.gov/issue/quality-and-safety-1
Progress made in the adoption of infrastructure, Safety I, and Safety II concepts in high- and middle- to
lower-income countries around the world support safe pedia…
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psnet.ahrq.gov/node/35345/psn-pdf
July 20, 2009 - Fixing healthcare from the inside, today.
July 20, 2009
Spear SJ. Fixing health care from the inside, today. Harv Bus Rev. 2005;83(9):78-91, 158.
https://psnet.ahrq.gov/issue/fixing-healthcare-inside-today
This commentary provides a broad overview of the issues facing health care systems in their efforts to
promot…
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psnet.ahrq.gov/node/47533/psn-pdf
June 19, 2019 - Patient Safety: A Health Affairs Briefing.
June 19, 2019
Project Hope.
https://psnet.ahrq.gov/issue/patient-safety-health-affairs-briefing
To Err Is Human was released almost 2 decades ago and continues to influence a growing area of study
aimed at improving health care and reducing medical error. This in-person a…
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psnet.ahrq.gov/node/42500/psn-pdf
August 14, 2013 - When should students learn about ethics,
professionalism and patient safety?
August 14, 2013
Walton M, Jeffery H, Van Staalduinen S, et al. When should students learn about ethics, professionalism
and patient safety? Clin Teach. 2013;10(4):224-9. doi:10.1111/tct.12029.
https://psnet.ahrq.gov/issue/when-should-stud…
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psnet.ahrq.gov/node/44387/psn-pdf
August 19, 2015 - Simulation in Surgical Training and Practice.
August 19, 2015
Brown KM, Paige JT, eds. Surg Clin North Am. 2015;95:695-918.
https://psnet.ahrq.gov/issue/simulation-surgical-training-and-practice
Simulation training is being used more broadly as an educational approach in health care. Articles in this
special issue…
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psnet.ahrq.gov/node/38561/psn-pdf
April 15, 2009 - Health-Care–Associated Infections in Hospitals:
Continuing Leadership Needed from HHS to Prioritize
Prevention Practices and Improve Data on These
Infections.
April 15, 2009
Subcommittee on Health Care, Committee on Finance, US Senate, Government Accountability Office,
GAO-09-516T (March 18, 2009)
https://psnet.…
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psnet.ahrq.gov/node/37793/psn-pdf
February 15, 2011 - Educating seniors to be patient safety self-advocates in
primary care.
February 15, 2011
Elder NC, Regan SL, Pallerla H, et al. Educating Seniors to Be Patient Safety Self-Advocates in Primary
Care. J Patient Saf. 2008;4(2). doi:10.1097/pts.0b013e318175d806.
https://psnet.ahrq.gov/issue/educating-seniors-be-patien…
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psnet.ahrq.gov/node/50572/psn-pdf
October 23, 2019 - Five reasons for optimism on World Patient Safety Day.
October 23, 2019
Fontana G, Flott K, Dhingra-Kumar N, et al. Five reasons for optimism on World Patient Safety Day.
Lancet. 2019;394(10203):993-995. doi:10.1016/S0140-6736(19)32134-8.
https://psnet.ahrq.gov/issue/five-reasons-optimism-world-patient-safety-day
…
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psnet.ahrq.gov/node/42327/psn-pdf
June 05, 2013 - Development and testing of tools to detect ambulatory
surgical adverse events.
June 5, 2013
Mull HJ, Borzecki A, Hickson K, et al. Development and testing of tools to detect ambulatory surgical
adverse events. J Patient Saf. 2013;9(2):96-102. doi:10.1097/PTS.0b013e31827d1a88.
https://psnet.ahrq.gov/issue/developme…
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psnet.ahrq.gov/node/60719/psn-pdf
July 22, 2020 - How real-time data can change the patient safety game.
July 22, 2020
Diesing G. How real-time data can change the patient safety game. J AHIMA. 2020;July 1.
https://psnet.ahrq.gov/issue/how-real-time-data-can-change-patient-safety-game
Use of data can improve the response of clinicians to patient concerns and deter…
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psnet.ahrq.gov/node/46385/psn-pdf
October 23, 2018 - The key to reducing doctors' misdiagnoses.
October 23, 2018
Landro L. Wall Street Journal. September 12, 2017.
https://psnet.ahrq.gov/issue/key-reducing-doctors-misdiagnoses
Misdiagnosis has gained recognition as an important patient safety problem. This newspaper article reports
on several areas of research and i…
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psnet.ahrq.gov/node/73098/psn-pdf
September 07, 2021 - Achieving Excellence in the Diagnosis of Acute
Cardiovascular Events: Proceedings of a Workshop–in
Brief.
September 7, 2021
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies
Press; 2021.
https://psnet.ahrq.gov/issue/achieving-excellence-diagnosis-acute-cardiovascula…
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psnet.ahrq.gov/node/836870/psn-pdf
April 26, 2022 - A Conversation Among Stakeholders on Medical
Malpractice.
April 6, 2022
Collaborative for Accountability and Improvement. April 26, 2022.
https://psnet.ahrq.gov/issue/conversation-among-stakeholders-medical-malpractice
Communication and resolution programs (CRP) can improve response to patients and families a…
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psnet.ahrq.gov/node/837001/psn-pdf
April 27, 2022 - Final Report of the Ockenden Review.
April 27, 2022
London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294.
https://psnet.ahrq.gov/issue/final-report-ockenden-review
Maternal and baby harm in healthcare is a sentinel event manifested by systemic failure. This report serves
as the final conclusions of an i…
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psnet.ahrq.gov/node/47983/psn-pdf
May 01, 2019 - Health systems and hospitals in pursuit of high reliability.
May 1, 2019
Cheney C. HealthLeaders Media. April 17, 2019.
https://psnet.ahrq.gov/issue/health-systems-and-hospitals-pursuit-high-reliability
This news article describes how a 19-hospital health system successfully applied high reliability principles
to …
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psnet.ahrq.gov/node/48179/psn-pdf
August 21, 2019 - Is WHO's surgical safety checklist being hyped?
August 21, 2019
Urbach DR, Dimick JB, Haynes AB, et al. Is WHO's surgical safety checklist being hyped? BMJ.
2019;366:l4700. doi:10.1136/bmj.l4700.
https://psnet.ahrq.gov/issue/whos-surgical-safety-checklist-being-hyped
Checklists are a popular yet controversial stra…
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psnet.ahrq.gov/node/41818/psn-pdf
July 02, 2014 - Perspective: a business school view of medical
interprofessional rounds: transforming rounding groups
into rounding teams.
July 2, 2014
Bharwani AM, Harris C, Southwick FS. Perspective: a business school view of medical interprofessional
rounds: transforming rounding groups into rounding teams. Acad Med. 2012;87(1…
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psnet.ahrq.gov/node/42147/psn-pdf
March 27, 2013 - The clinical safety of disabled patients: proposal for a
methodology for analysis of health care risks and specific
measures for improvement.
March 27, 2013
Perea-Pérez B, Labajo-González E, Bratos-Murillo M, et al. The clinical safety of disabled patients:
proposal for a methodology for analysis of health care ri…
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psnet.ahrq.gov/node/37726/psn-pdf
April 30, 2008 - Patient Safety and Quality: An Evidence-Based Handbook
for Nurses.
April 30, 2008
Hughes RG, ed. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No.
08-0043.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-evidence-based-handbook-nurses
This handbook prepared by the Age…
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psnet.ahrq.gov/node/42442/psn-pdf
July 24, 2013 - Using Plan Do Study Act to transform a simulation center.
July 24, 2013
Murphy JI. Using Plan Do Study Act to Transform a Simulation Center. Clin Simul Nurs. 2012;9(7).
doi:10.1016/j.ecns.2012.03.002.
https://psnet.ahrq.gov/issue/using-plan-do-study-act-transform-simulation-center
This commentary describes the res…