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psnet.ahrq.gov/issue/target-focused-medical-emergency-team-training-using-human-patient-simulator-effects
May 23, 2013 - Study
Target-focused medical emergency team training using a human patient simulator: effects on behaviour and attitude.
Citation Text:
Wallin C-J, Meurling L, Hedman L, et al. Target-focused medical emergency team training using a human patient simulator: effects on behaviour and atti…
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psnet.ahrq.gov/issue/failure-follow-medication-changes-made-hospital-discharge-associated-adverse-events-30-days
October 16, 2019 - Study
Failure to follow medication changes made at hospital discharge is associated with adverse events in 30 days.
Citation Text:
Weir DL, Motulsky A, Abrahamowicz M, et al. Failure to follow medication changes made at hospital discharge is associated with adverse events in 30 days. Hea…
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psnet.ahrq.gov/issue/improving-patient-safety-governance-and-systems-through-learning-successes-and-failures
May 08, 2017 - Study
Improving patient safety governance and systems through learning from successes and failures: qualitative surveys and interviews with international experts.
Citation Text:
Hibbert PD, Stewart S, Wiles LK, et al. Improving patient safety governance and systems through learning from …
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psnet.ahrq.gov/node/45672/psn-pdf
January 01, 2025 - Healthcare Simulation Dictionary, Third Edition.
December 10, 2024
Lioce L, Lopreiato J, Anderson M, et al, eds and the Terminology and Concepts Working Group. Rockville,
MD: Agency for Healthcare Research and Quality; January 2025. AHRQ Publication No. 24-0077.
https://psnet.ahrq.gov/issue/healthcare-simulation-di…
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psnet.ahrq.gov/node/836791/psn-pdf
August 21, 2024 - TeamSTEPPS for Diagnosis Improvement.
August 21, 2024
TeamSTEPPS for Diagnosis Improvement.
https://psnet.ahrq.gov/issue/teamstepps-diagnosis-improvement
The recognition of diagnosis as a team activity is energizing new diagnostic process initiatives. Building on
the established TeamSTEPPS® principles, this new Te…
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psnet.ahrq.gov/node/40395/psn-pdf
May 13, 2021 - Hospital Compare.
May 13, 2021
Centers for Medicare & Medicaid Services.
https://psnet.ahrq.gov/issue/hospital-compare
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available
information on the quality of Medicare-certified hospital care through this Web site. The site inclu…
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psnet.ahrq.gov/node/45932/psn-pdf
May 18, 2017 - Polypharmacy.
May 18, 2017
Zagaria MAE, ed. Clin Geriatr Med. 2017;33:153-292.
https://psnet.ahrq.gov/issue/polypharmacy
Older patients are likely to be prescribed multiple medications, which can increase risks. Articles in this
special issue explore polypharmacy in a variety of care settings and provide tactics f…
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psnet.ahrq.gov/node/37188/psn-pdf
September 19, 2007 - Teaming up to prevent 'crashes': some hospitals give
patients the power to get extra help, stat.
September 19, 2007
Wang SS. Washington Post. August 31, 2007.
https://psnet.ahrq.gov/issue/teaming-prevent-crashes-some-hospitals-give-patients-power-get-extra-help-
stat
This article discusses the advent of rapid res…
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psnet.ahrq.gov/node/42158/psn-pdf
April 03, 2013 - Long-term effects of a perioperative safety checklist from
the viewpoint of personnel.
April 3, 2013
Böhmer AB, Kindermann P, Schwanke U, et al. Long-term effects of a perioperative safety checklist from
the viewpoint of personnel. Acta Anaesthesiol Scand. 2013;57(2):150-7. doi:10.1111/aas.12020.
https://psnet.ahr…
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psnet.ahrq.gov/node/40108/psn-pdf
July 28, 2013 - Toward Improving the Outcome of Pregnancy: Enhancing
Perinatal Health Through Quality, Safety and Performance
Initiatives (TIOP III).
July 28, 2013
Berns SD, ed. White Plains, NY: March of Dimes; December 2010.
https://psnet.ahrq.gov/issue/toward-improving-outcome-pregnancy-enhancing-perinatal-health-through-
qua…
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psnet.ahrq.gov/node/35984/psn-pdf
January 02, 2017 - The clinical transformation of Ascension Health:
eliminating all preventable injuries and deaths.
January 2, 2017
Pryor DB, Tolchin SF, Hendrich A, et al. The clinical transformation of Ascension Health: eliminating all
preventable injuries and deaths. Jt Comm J Qual Patient Saf. 2006;32(6):299-308.
https://psnet.…
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psnet.ahrq.gov/node/846766/psn-pdf
March 29, 2023 - The prisoner.
March 29, 2023
Kent S. NJ.com. March 12, 2023.
https://psnet.ahrq.gov/issue/prisoner
Heuristics, uncertainty, and bias are contributors to diagnostic error, overuse, and treatment delay. This
story describes the care experience of an adolescent patient whose rare immune system condition was
initiall…
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psnet.ahrq.gov/node/47280/psn-pdf
October 15, 2018 - Master of Healthcare Quality and Safety.
October 15, 2018
Harvard Medical School.
https://psnet.ahrq.gov/issue/master-healthcare-quality-and-safety
This one-year degree program will train clinicians and health care executives to lead safety and quality
improvement initiatives. Participants will learn how to develo…
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psnet.ahrq.gov/node/72863/psn-pdf
March 17, 2021 - 7 ways to prevent medical errors.
March 17, 2021
Caceres V. US News World Report. March 1, 2021.
https://psnet.ahrq.gov/issue/7-ways-prevent-medical-errors
Patients and families have an important role in reducing potential for error and harm. This article highlights
a set of tactics for patients to enhan…
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psnet.ahrq.gov/node/74246/psn-pdf
January 12, 2022 - Patient Safety.
January 12, 2022
Dean J, Subbe C, eds. Future Healthc J. 2021;8(3):e559-e618.
https://psnet.ahrq.gov/issue/patient-safety-23
Full realization of the patient voice as a resource for safety is challenging. This special section provides
global perspectives examining cultural, organizational, and syste…
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psnet.ahrq.gov/node/39742/psn-pdf
August 09, 2013 - Patient Safety, 2nd edition.
August 9, 2013
doi:10.1002/9781444323856.
https://psnet.ahrq.gov/issue/patient-safety-2nd-edition
Dr. Charles Vincent, a psychologist by training, is unquestionably one of the founders of the modern patient
safety movement and continues to publish groundbreaking research in the field. …
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psnet.ahrq.gov/node/45306/psn-pdf
August 17, 2016 - Indiana Patient Safety Center.
August 17, 2016
Indiana Hospital Association; IHA.
https://psnet.ahrq.gov/issue/indiana-patient-safety-center
Launched in 2006, the Indiana Patient Safety Center (IPSC) is dedicated to promoting safety culture and
reliable systems of care in the state. This website provides resources…
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psnet.ahrq.gov/node/34136/psn-pdf
January 29, 2018 - Institute for Healthcare Improvement.
January 29, 2018
53 State Street, 19th Floor, Boston, MA 02109. 617-301-4800, info@ihi.org.
https://psnet.ahrq.gov/issue/institute-healthcare-improvement
The Institute for Healthcare Improvement (IHI) is a not-for-profit organization promoting health improvement
by advancing t…
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psnet.ahrq.gov/node/845346/psn-pdf
March 01, 2023 - The relationship between safety climate and safety
performance: a review.
March 1, 2023
Syed-Yahya SNN, Idris MA, Noblet AJ. The relationship between safety climate and safety performance: a
review. J Safety Res. 2022;83:105-118. doi:10.1016/j.jsr.2022.08.008.
https://psnet.ahrq.gov/issue/relationship-between-safe…
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psnet.ahrq.gov/node/35319/psn-pdf
September 14, 2005 - Perceived impact of duty hours limits on the
fragmentation of patient care: results from an academic
health center.
September 14, 2005
Keating RJ; LaRusso NF; Kolars JC.
https://psnet.ahrq.gov/issue/perceived-impact-duty-hours-limits-fragmentation-patient-care-results-
academic-health-center
The authors surveyed…