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psnet.ahrq.gov/node/35540/psn-pdf
August 05, 2009 - Lost in translation: challenges and opportunities in
physician-to-physician communication during patient
handoffs.
August 5, 2009
Solet DJ, Norvell M, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-
physician communication during patient handoffs. Acad Med. 2005;80(12):1094-9.
…
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March 21, 2017 - How often are potential patient safety events present on
admission?
March 21, 2017
Houchens RL, Elixhauser A, Romano PS. How often are potential patient safety events present on
admission? Jt Comm J Qual Patient Saf. 2008;34(3):154-63.
https://psnet.ahrq.gov/issue/how-often-are-potential-patient-safety-events-pres…
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psnet.ahrq.gov/node/46467/psn-pdf
October 18, 2017 - The Role of Clinical Learning Environments in Preparing
New Clinicians to Engage in Patient Safety.
October 18, 2017
Disch J, Kilo CM, Passiment M, Wagner R, Weiss KB; National Collaborative for Improving the Clinical
Learning Environment. Chicago, IL: Accreditation Council for Graduate Medical Education; 2017.
ht…
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psnet.ahrq.gov/node/47733/psn-pdf
April 27, 2019 - Impact of the Agency for Healthcare Research and
Quality's Safety Program for Perinatal Care.
April 27, 2019
Kahwati LC, Sorensen A, Teixeira-Poit S, et al. Impact of the Agency for Healthcare Research and
Quality's Safety Program for Perinatal Care. Jt Comm J Qual Patient Saf. 2019;45(4):231-240.
doi:10.1016/j.jc…
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psnet.ahrq.gov/node/73397/psn-pdf
June 16, 2021 - Safe opioid prescribing: a prognostic machine learning
approach to predicting 30-day risk after an opioid
dispensation in Alberta, Canada.
June 16, 2021
Sharma V, Kulkarni V, Eurich DT, et al. Safe opioid prescribing: a prognostic machine learning approach to
predicting 30-day risk after an opioid dispensation in …
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psnet.ahrq.gov/node/50458/psn-pdf
October 09, 2019 - Success of a resident-led safety council: a model for
satisfying CLER Pathways to Excellence patient safety
goals.
October 9, 2019
Cohen SP, Pelletier JH, Ladd JM, et al. Success of a resident-led safety council: a model for satisfying
CLER Pathways to Excellence patient safety goals. J Gen Intern Med. 2019;11(2):…
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psnet.ahrq.gov/node/848110/psn-pdf
April 26, 2023 - Candello, established as a division of the Risk
Management Foundation of the Harvard Medical Institutions Incorporated … by and used with permission
of The Risk Management Foundation of the Harvard Medical Institutions Incorporated
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psnet.ahrq.gov/node/849660/psn-pdf
May 31, 2023 - Strategies to Improve Organizational Health Literacy.
May 31, 2023
Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
Background
Health literacy is important at both the personal …
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psnet.ahrq.gov/node/36549/psn-pdf
March 21, 2017 - Patients' concerns about medical errors during
hospitalization.
March 21, 2017
Burroughs TE, Waterman AD, Gallagher TH, et al. Patients' concerns about medical errors during
hospitalization. Jt Comm J Qual Patient Saf. 2007;33(1):5-14.
https://psnet.ahrq.gov/issue/patients-concerns-about-medical-errors-during-hosp…
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psnet.ahrq.gov/node/36753/psn-pdf
April 30, 2014 - Medication errors in the outpatient setting: classification
and root cause analysis.
April 30, 2014
Friedman AL, Geoghegan SR, Sowers NM, et al. Medication errors in the outpatient setting: classification
and root cause analysis. Arch Surg. 2007;142(3):278-83; discussion 284.
https://psnet.ahrq.gov/issue/medicatio…
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psnet.ahrq.gov/node/34775/psn-pdf
February 07, 2019 - Escape Fire: Lessons for the Future of Health Care.
February 7, 2019
Berwick DM. Washington DC: Commonwealth Fund; 2002.
https://psnet.ahrq.gov/issue/escape-fire-lessons-future-health-care
This report represents an edited version of Donald Berwick’s Plenary Address presented at the Institute for
Healthcare Improve…
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psnet.ahrq.gov/node/45701/psn-pdf
December 21, 2016 - Clinical decision support for drug related events: moving
towards better prevention.
December 21, 2016
Kane-Gill SL, Achanta A, Kellum JA, et al. Clinical decision support for drug related events: Moving towards
better prevention. World J Crit Care Med. 2016;5(4):204-211.
https://psnet.ahrq.gov/issue/clinical-deci…
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psnet.ahrq.gov/node/41352/psn-pdf
May 09, 2012 - ASHP national survey of pharmacy practice in hospital
settings: dispensing and administration—2011.
May 9, 2012
Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital
settings: Dispensing and administration—2011. American Journal of Health-System Pharmacy. 2012;69(9).
doi…
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psnet.ahrq.gov/node/35623/psn-pdf
August 05, 2009 - Changing and sustaining medical students' knowledge,
skills, and attitudes about patient safety and medical
fallibility.
August 5, 2009
Madigosky WS, Headrick LA, Nelson K, et al. Changing and sustaining medical students' knowledge, skills,
and attitudes about patient safety and medical fallibility. Acad Med. 2006…
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psnet.ahrq.gov/node/36551/psn-pdf
February 17, 2011 - An intervention to decrease catheter-related bloodstream
infections in the ICU.
February 17, 2011
Pronovost P, Needham DM, Berenholtz SM, et al. An intervention to decrease catheter-related
bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-2732.
https://psnet.ahrq.gov/issue/intervention-decrease-c…
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psnet.ahrq.gov/node/47524/psn-pdf
June 19, 2019 - Learning from patients' experiences related to diagnostic
errors is essential for progress in patient safety.
June 19, 2019
Giardina TD, Haskell H, Menon S, et al. Learning From Patients' Experiences Related To Diagnostic Errors
Is Essential For Progress In Patient Safety. Health Aff (Millwood). 2018;37(11):1821-18…
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psnet.ahrq.gov/node/48165/psn-pdf
August 28, 2019 - Competencies for improving diagnosis: an
interprofessional framework for education and training in
health care.
August 28, 2019
Olson A, Rencic J, Cosby K, et al. Competencies for improving diagnosis: an interprofessional framework
for education and training in health care. Diagnosis (Berl). 2019;6(4):335-341. doi…
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psnet.ahrq.gov/node/866841/psn-pdf
September 23, 2024 - example, may not need to hire
coaches for staff education if the standardized measures are properly incorporated
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psnet.ahrq.gov/node/42692/psn-pdf
April 21, 2015 - Surgical skill and complication rates after bariatric
surgery.
April 21, 2015
Birkmeyer JD, Finks JF, O'Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl
J Med. 2013;369(15):1434-1442. doi:10.1056/NEJMsa1300625.
https://psnet.ahrq.gov/issue/surgical-skill-and-complication-rates…
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psnet.ahrq.gov/node/39748/psn-pdf
August 11, 2010 - Information transfer and communication in surgery: a
systematic review.
August 11, 2010
Nagpal K, Vats A, Lamb B, et al. Information transfer and communication in surgery: a systematic review.
Ann Surg. 2010;252(2):225-39. doi:10.1097/SLA.0b013e3181e495c2.
https://psnet.ahrq.gov/issue/information-transfer-and-comm…