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  1. psnet.ahrq.gov/issue/special-focus-issue-patient-safety
    November 06, 2015 - in this special issue explore strategies to establish a culture of safety in health care settings, including
  2. psnet.ahrq.gov/issue/magnet-support-patient-safety
    June 13, 2007 - Articles in this special issue highlight organizational elements that contribute to patient safety, including
  3. psnet.ahrq.gov/issue/biggest-mistake-doctors-make
    October 09, 2013 - This newspaper article describes efforts to prevent diagnostic errors , including improving follow-up
  4. psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
    February 26, 2025 - AHRQ in 2008, was retired in March 2021; AHRQ now offers select content from the Innovations Exchange, including … improvement (QI) facilitator, project manager, process owners (frontline staff involved in care transitions, including … hospitalized patients and their family members do not adequately understand their post-discharge care needs, including … improvement (QI) facilitator, project manager, process owners (frontline staff involved in care transitions, including … Establishing an organizational framework for quality improvement:  Several initial steps are required, including
  5. psnet.ahrq.gov/issue/ambulatory-surgery-center-survey-patient-safety-culture
    December 24, 2008 - The survey is presented with additional resources to help organizations assess their safety culture, including
  6. psnet.ahrq.gov/issue/patient-safety-12
    April 26, 2012 - Patient Safety Consortium with a focus on the effect patient partnerships on initiative priority areas including
  7. psnet.ahrq.gov/issue/pharmacy-education-and-practice
    September 27, 2016 - This special issue covers several topics including strategies to reduce the susceptibility of hospitalized
  8. psnet.ahrq.gov/issue/when-doctors-get-wrong-patient
    December 14, 2016 - article reviews recent research on this issue and suggests several system approaches for improvement, including
  9. psnet.ahrq.gov/issue/patient-safety-and-managing-risk-nursing
    March 27, 2017 - The authors also cover key safety topics, including root cause analysis , human factors , and safety
  10. psnet.ahrq.gov/issue/hard-look-hard-stops-and-workarounds-acute-care-setting
    June 26, 2013 - This article presents system-level recommendations to effectively introduce hard stops such as including
  11. psnet.ahrq.gov/issue/nurses-say-stress-interferes-caring-their-patients
    August 29, 2018 - This news article explores organizational factors that contribute to nurse burnout , including low
  12. psnet.ahrq.gov/issue/patient-safe-future
    March 04, 2010 - The report outlines existing challenges and strategies to drive system improvement, including leadership
  13. psnet.ahrq.gov/issue/alarm-management-first-things-first-using-reliable-data-eliminate-unnecessary-alarms
    July 29, 2009 - augment alarm management and offers recommendations for hospitals working to reduce unnecessary alarms, including
  14. psnet.ahrq.gov/issue/patient-safety-certificate-course
    August 07, 2013 - This online course offers three modules designed to build awareness of key patient safety topics , including
  15. psnet.ahrq.gov/issue/avoidable-death-three-year-old-child-sepsis
    August 31, 2016 - service in the course of his care, the report recommends organization-wide efforts to improve safety, including
  16. psnet.ahrq.gov/issue/how-hospital-design-saves-lives
    July 06, 2011 - This article discusses how hospital design, including standardized operating rooms, better ventilation
  17. psnet.ahrq.gov/issue/surgeon-heal-thyself-optimising-surgical-performance-managing-stress
    November 10, 2017 - The author offers recommendations for surgeons to help manage stress levels, including noise reduction
  18. psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
    April 12, 2023 - The admitting physician was concerned that the patient might require subspecialty care, including dermatology … 44% of patients with acute myocardial infarction) ( 2,3 ), and those who are critically ill ( 4 ), including … As we know from other hospital-based care transitions, including patient discharge and intrahospital … Telemedicine, including teleconsultation, is one information exchange modality that has been used to … needed to direct the development of best practice guidelines with regard to interhospital transfer, including
  19. psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
    March 18, 2020 - Surgical factors can also increase the risk of aspiration including head-down positioning and certain … Additional steps should be considered to confirm there are minimal contents in the stomach including … The emergency airway algorithm dictates that “alternative intubation approaches” be attempted, including … All attempts to secure an airway in an emergency must be made, including performing a surgical airway … Ventilate the patient who has aspirated with 100% oxygen, utilizing airway adjuncts including LMAs as
  20. psnet.ahrq.gov/web-mm/medical-devices-wild
    March 27, 2024 - features integrated into the product.( 6 ) Second, environments in which any medical devices are used, including … patient bed and SCD [sequential compression device] tubes) ( 7 ) and other components of a work system, including … Another, safer design could involve consolidating all bed status information, including lock status, … Introducing any new technology into these systems, including medical devices, can result in both anticipated … Stakeholders (including clinicians, patients, engineers, device manufacturers) should collaborate for

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