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psnet.ahrq.gov/node/848036/psn-pdf
April 26, 2023 - Using a learning system approach to improve safety for
prone-position ventilation patients.
April 26, 2023
Thomas AL, Graham KL, Davila S, et al. Using a learning system approach to improve safety for prone-
position ventilation patients. J Patient Saf. 2023;19(3):180-184. doi:10.1097/pts.0000000000001108.
https:/…
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psnet.ahrq.gov/node/73291/psn-pdf
May 19, 2021 - How can never event data be used to reflect or improve
hospital safety performance?
May 19, 2021
Olivarius?McAllister J, Pandit M, Sykes A, et al. How can never event data be used to reflect or improve
hospital safety performance? Anaesthesia. 2021;76(12):1616-1624. doi:10.1111/anae.15476.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/42686/psn-pdf
April 16, 2019 - Improving the quality of health care: what's taking so
long?
April 16, 2019
Chassin MR. Improving The Quality Of Health Care: What’s Taking So Long? Health Aff.
2013;32(10):1761-1765. doi:10.1377/hlthaff.2013.0809.
https://psnet.ahrq.gov/issue/improving-quality-health-care-whats-taking-so-long
Almost a decade-and…
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psnet.ahrq.gov/node/60681/psn-pdf
January 01, 2022 - Failure to rescue deteriorating patients: a systematic
review of root causes and improvement strategies.
July 16, 2020
Burke JR, Downey C, Almoudaris AM. Failure to rescue deteriorating patients: a systematic review of root
causes and improvement strategies. J Patient Saf. 2022;18(1):e140-e155.
doi:10.1097/pts.000…
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psnet.ahrq.gov/node/866733/psn-pdf
September 18, 2024 - A coproduced family reporting intervention to improve
safety surveillance and reduce disparities.
September 18, 2024
Khan A, Baird JD, Mauskar S, et al. A coproduced family reporting intervention to improve safety
surveillance and reduce disparities. Pediatrics. 2024;154(4):e2023065245. doi:10.1542/peds.2023-065245…
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psnet.ahrq.gov/node/46092/psn-pdf
July 11, 2017 - Development of a research agenda to identify evidence-
based strategies to improve physician wellness and
reduce burnout.
July 11, 2017
Dyrbye LN, Trockel M, Frank E, et al. Development of a Research Agenda to Identify Evidence-Based
Strategies to Improve Physician Wellness and Reduce Burnout. Ann Intern Med. 2017…
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psnet.ahrq.gov/node/847541/psn-pdf
April 12, 2023 - Improving medication safety in a paediatric hospital: a
mixed-methods evaluation of a newly implemented
computerised provider order entry system.
April 12, 2023
Liang MQ, Thibault M, Jouvet P, et al. BMJ Health Care Inform. 2023;30(1):e100622.
https://psnet.ahrq.gov/issue/improving-medication-safety-paediatric-hos…
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psnet.ahrq.gov/node/846757/psn-pdf
March 29, 2023 - Managing interruptions to improve diagnostic decision-
making: strategies and recommended research agenda.
March 29, 2023
Sloane JF, Donkin C, Newell BR, et al. Managing interruptions to improve diagnostic decision-making:
strategies and recommended research agenda. J Gen Intern Med. 2023;38(6):1526-1531.
doi:10.1…
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psnet.ahrq.gov/node/60726/psn-pdf
January 01, 2021 - User-testing guidelines to improve the safety of
intravenous medicines administration: a randomised in
situ simulation study.
July 29, 2020
Jones MD, McGrogan A, Raynor DK, et al. User-testing guidelines to improve the safety of intravenous
medicines administration: a randomised in situ simulation study. BMJ Qual …
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psnet.ahrq.gov/node/866313/psn-pdf
July 17, 2024 - Towards understanding and improving medication safety
for patients with mental illness in primary care: a
multimethod study.
July 17, 2024
Ayre MJ, Lewis PJ, Phipps DL, et al. Towards understanding and improving medication safety for patients
with mental illness in primary care: a multimethod study. Health Expect.…
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psnet.ahrq.gov/node/47240/psn-pdf
March 06, 2019 - Improving detection of intraoperative medical errors
(iMEs) and intraoperative adverse events (iAEs) and their
contribution to postoperative outcomes.
March 6, 2019
Chen Q, Rosen AK, Amirfarzan H, et al. Improving detection of intraoperative medical errors (iMEs) and
intraoperative adverse events (iAEs) and their …
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psnet.ahrq.gov/node/45096/psn-pdf
May 05, 2016 - Patient safety at the crossroads.
May 5, 2016
Gandhi TK, Berwick DM, Shojania KG. Patient Safety at the Crossroads. JAMA. 2016;315(17):1829-30.
doi:10.1001/jama.2016.1759.
https://psnet.ahrq.gov/issue/patient-safety-crossroads
This commentary discusses findings from the National Patient Safety Foundation report in…
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psnet.ahrq.gov/node/41043/psn-pdf
May 24, 2012 - Toward improving patient safety through voluntary peer-
to-peer assessment.
May 24, 2012
Hudson DW, Holzmueller CG, Pronovost P, et al. Toward improving patient safety through voluntary peer-
to-peer assessment. Am J Med Qual. 2012;27(3):201-9. doi:10.1177/1062860611421981.
https://psnet.ahrq.gov/issue/toward-impr…
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psnet.ahrq.gov/node/841474/psn-pdf
January 01, 2023 - Factors that affect opioid quality improvement initiatives
in primary care: insights from ten health systems.
December 14, 2022
Childs E, Tano CA, Mikosz CA, et al. Factors that affect opioid quality improvement initiatives in primary
care: insights from ten health systems. Jt Comm J Qual Patient Saf. 2023;49(1):26…
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psnet.ahrq.gov/node/837731/psn-pdf
July 27, 2022 - Predictors and outcomes of patient safety culture: a
cross-sectional comparative study.
July 27, 2022
Mrayyan MT. Predictors and outcomes of patient safety culture: a cross-sectional comparative study. BMJ
Open Qual. 2022;11(3):e001889. doi:10.1136/bmjoq-2022-001889.
https://psnet.ahrq.gov/issue/predictors-and-out…
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psnet.ahrq.gov/node/46506/psn-pdf
October 11, 2017 - Getting Ahead of Harm Before It Happens: A Guide About
Proactive Analysis for Improving Surgical Care Safety.
October 11, 2017
Wiley K, Davies JM. Edmonton, AB: Canadian Patient Safety Institute; 2017.
https://psnet.ahrq.gov/issue/getting-ahead-harm-it-happens-guide-about-proactive-analysis-improving-
surgical-car…
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psnet.ahrq.gov/node/35404/psn-pdf
March 11, 2011 - Improving patient safety by identifying side effects from
introducing bar coding in medication administration.
March 11, 2011
Patterson ES, Cook RI, Render ML. Improving patient safety by identifying side effects from introducing bar
coding in medication administration. J Am Med Inform Assoc. 2002;9(5):540-53.
htt…
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psnet.ahrq.gov/node/73171/psn-pdf
April 21, 2021 - Patient safety and quality improvement adaptation during
the COVID-19 pandemic.
April 21, 2021
Sterling RS, Berry SA, Herzke C, et al. Patient safety and quality improvement adaptation during the
COVID-19 pandemic. Am J Med Qual. 2021;36(1):57-59. doi:10.1097/01.jmq.0000733448.50484.a8.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/837331/psn-pdf
June 08, 2022 - Can a targeted educational approach improve situational
awareness in paramedicine during 911 emergency calls?
June 8, 2022
Hunter J, Porter M, Cody P, et al. Can a targeted educational approach improve situational awareness in
paramedicine during 911 emergency calls? Int Emerg Nurs. 2022;63:101174.
doi:10.1016/j.i…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_sr-execs_facnotes.docx
December 01, 2017 - Facilitator Guide: Engage Senior Executives in Surgical Site Infection Prevention Work
Engaging Senior Executives – Facilitator Notes
Slide Title and Commentary
Slide Number and Slide
Title Slide
Engaging Senior Executives
SAY:
In this module we will discuss the importance of senior engagement on your safety pr…