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psnet.ahrq.gov/issue/national-voluntary-consensus-standards-patient-safety-measures-consensus-report
January 11, 2013 - The measures—relevant to specific types of health care–associated infections (including central line–associated
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psnet.ahrq.gov/issue/report-mid-staffordshire-nhs-foundation-trust-public-inquiry
November 06, 2015 - The extensive three-volume report outlines 290 proposals, including drastic measures to improve patient
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psnet.ahrq.gov/issue/perioperative-medication-errors-uncovering-risk-behind-drapes
March 27, 2018 - The authors provide recommendations to reduce risks of error, including using barcode medication administration
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psnet.ahrq.gov/issue/misery-doctors-first-days
December 02, 2015 - This magazine article reports on the challenges first-year residents face, including burnout and gaps
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psnet.ahrq.gov/issue/parents-perceptions-medical-errors
April 27, 2010 - This study found that perceived medical errors have a negative impact on patients and families, including
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psnet.ahrq.gov/issue/vanishing-nonforensic-autopsy
February 09, 2011 - The authors discuss the implications of this problem and potential solutions, including the establishment
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psnet.ahrq.gov/issue/essential-guide-patient-safety-officers-second-edition
February 15, 2017 - Chapters cover strategies to implement lasting improvements including: developing a culture of safety
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psnet.ahrq.gov/issue/maryland-hospital-patient-safety-program-annual-report
December 24, 2008 - The authors recommend several corrective actions to enhance improvement work, including board and executive
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psnet.ahrq.gov/issue/structural-and-organizational-issues-patient-safety-comparison-health-care-other-high-hazard
February 09, 2011 - does and discusses complementary theories of organizational safety in other high-hazard organizations, including
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psnet.ahrq.gov/issue/selected-medication-safety-risks-manage-2016-might-otherwise-fall-radar-screen-part-1-and
March 09, 2016 - two-part newsletter article reviews risks associated with medication use and strategies to enhance safety, including
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psnet.ahrq.gov/node/46135/psn-pdf
July 11, 2017 - associated-events
Patients requiring intensive care are particularly vulnerable to preventable adverse events, including … Participating hospitals were able to significantly reduce the rate of ventilator-associated adverse events
(including
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psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
April 27, 2022 - Materials related to medication management issues, including reducing ADEs in older adults, reducing … precise factors that optimize the efficacy of CDS interventions in reducing PIM prescribing rates, including … Several provider tools are available to assist with identifying PIMs, including the AGS Beers Criteria … academic emergency department after the implementation of electronic medical record-based work-aids, including … addition to state regulations and guidelines targeting opioid prescribing behavior, other interventions , including
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psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
August 30, 2023 - in a medical error or adverse event may experience a range of emotional and psychological trauma including … Healthcare worker burnout is a national crisis and is caused by many different factors, including moral … need. 3 Manifestations of burnout can be physical, such as exhaustion and insomnia, or psychological, including … they are identified, organizations can improve efforts and develop ways to support healthcare workers including … Burnout can impact workers at all levels, including those who are not direct care providers such as quality
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psnet.ahrq.gov/node/72834/psn-pdf
March 10, 2021 - Communication throughout a patient’s
interaction with the health care system, including during diagnosis … , treatment, and transitions to other
settings of care including the home, helps to ensure patients … discharge, and one-quarter of those patients did not understand
the next steps after leaving the ED, including … This type of inadequate communication at handoffs
contributes to adverse events, including medication … These practices have been shown to have a
positive impact on outcomes, including readmissions.
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psnet.ahrq.gov/web-mm/inflicting-confusion
August 04, 2021 - GI recommended sending stool studies, including for Clostridium difficile infection (CDI), and suggested … disease is the second most common.( 1 ) Crohn disease is associated with extraintestinal manifestations, including … severity and rule out CMV.( 1 ) In patients with increasing diarrhea or abdominal pain, stool studies including … and reduced efficacy.( 15 ) There are several unique risks associated with anti-TNF therapies, including … Other risks, including other infections, acute and delayed infusion reactions, and lupus-like syndromes
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psnet.ahrq.gov/taxonomy/term/3440
April 10, 2025 - most often used, situational awareness includes awareness of fatigue and stress among team members (including
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psnet.ahrq.gov/issue/strategies-enhance-adoption-ventilator-associated-pneumonia-prevention-interventions
July 10, 2017 - This systematic review identifies several strategies, including standardization of care processes, performing
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psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2014-user-comparative-database-report
May 11, 2016 - comparative database presents benchmarking data for safety culture from 653 hospitals nationwide, including
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psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2011-user-comparative-database-report
September 14, 2011 - database presents benchmarking data for safety culture from more than 1000 hospitals nationwide, including
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psnet.ahrq.gov/issue/2008-update-consumers-views-patient-safety-and-quality-information
October 02, 2013 - 22% reporting having visited a clinician who did not have access to all of their health information (including