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www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/valuewebcasttranscript.pdf
January 09, 2018 - We didn't have a single initiative to
address this. … But, for instance, with the noise initiative, we're
measuring that via patient complaints.
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psnet.ahrq.gov/node/837192/psn-pdf
May 25, 2022 - Declaration to Advance Patient Safety.
May 25, 2022
National Steering Committee for Patient Safety. Boston, MA: Institute for Healthcare Improvement; May
2022.
https://psnet.ahrq.gov/issue/declaration-advance-patient-safety
Leadership commitment is crucial to attaining sustainable improvement in patient safety. Th…
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psnet.ahrq.gov/node/838925/psn-pdf
March 03, 2025 - Improving Quality and Safety in Healthcare.
March 3, 2025
Dixon-Woods M, Martin G, eds. Cambridge, UK: Cambridge University Press; 2022-2025.
https://psnet.ahrq.gov/issue/improving-quality-and-safety-healthcare
Improvement activities are complex initiatives that require synergistic actions by organizations to be
s…
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psnet.ahrq.gov/node/60972/psn-pdf
January 30, 2003 - Unequal Treatment: Confronting Racial and Ethnic
Disparities in Health Care.
January 30, 2003
Smedley BD, Stith AY, Nelson AR, eds and Institute of Medicine. Washington, DC; The National
Academies Press: 2003. ISBN 9780309082655.
https://psnet.ahrq.gov/issue/unequal-treatment-confronting-racial-and-ethnic-dis…
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psnet.ahrq.gov/node/47324/psn-pdf
November 07, 2018 - Engaging patients to improve quality of care: a
systematic review.
November 7, 2018
Bombard Y, Baker R, Orlando E, et al. Engaging patients to improve quality of care: a systematic review.
Implement Sci. 2018;13(1):98. doi:10.1186/s13012-018-0784-z.
https://psnet.ahrq.gov/issue/engaging-patients-improve-quality-ca…
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psnet.ahrq.gov/node/845650/psn-pdf
March 08, 2023 - Towards conceptualizing patients as partners in health
systems: a systematic review and descriptive synthesis.
March 8, 2023
Vanstone M, Canfield C, Evans C, et al. Towards conceptualizing patients as partners in health systems: a
systematic review and descriptive synthesis. Health Res Policy Syst. 2023;21(1):12. d…
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psnet.ahrq.gov/node/45321/psn-pdf
August 01, 2017 - Peer support for clinicians: a programmatic approach.
August 1, 2017
Shapiro J, Galowitz P. Peer Support for Clinicians: A Programmatic Approach. Acad Med.
2016;91(9):1200-4. doi:10.1097/ACM.0000000000001297.
https://psnet.ahrq.gov/issue/peer-support-clinicians-programmatic-approach
Peer support programs can help …
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psnet.ahrq.gov/node/45111/psn-pdf
May 11, 2016 - Educational opportunities with postevent debriefing.
May 11, 2016
Mullan PC, Kessler DO, Cheng A. Educational opportunities with postevent debriefing. JAMA.
2014;312(22):2333-4. doi:10.1001/jama.2014.15741.
https://psnet.ahrq.gov/issue/educational-opportunities-postevent-debriefing
Real-time or near real-time lear…
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psnet.ahrq.gov/node/838192/psn-pdf
September 28, 2022 - When medical error becomes personal, activism becomes
painful.
September 28, 2022
Millenson M. Forbes. September 16, 2022.
https://psnet.ahrq.gov/issue/when-medical-error-becomes-personal-activism-becomes-painful
Unnecessary medication infusions indicate weaknesses in medication service processes. While no harm
w…
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psnet.ahrq.gov/node/47220/psn-pdf
September 12, 2018 - Strategically Advancing Patient and Family Advisory
Councils in New York State Hospitals.
September 12, 2018
Bethesda, MD: Institute for Patient- and Family-Centered Care; June 2018.
https://psnet.ahrq.gov/issue/strategically-advancing-patient-and-family-advisory-councils-new-york-state-
hospitals
Hospital patien…
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psnet.ahrq.gov/node/854637/psn-pdf
October 18, 2023 - A scoping review of clinical handover mnemonic devices.
October 18, 2023
Yung AHW, Pak CS, Watson B. A scoping review of clinical handover mnemonic devices. Int J Qual Health
Care. 2023;35(3):mzad065. doi:10.1093/intqhc/mzad065.
https://psnet.ahrq.gov/issue/scoping-review-clinical-handover-mnemonic-devices
Cogniti…
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psnet.ahrq.gov/node/846458/psn-pdf
March 22, 2024 - National Healthcare Quality and Disparities Report
Chartbook on Patient Safety.
March 22, 2024
Rockville, MD: Agency for Healthcare Research and Quality; March 2024. AHRQ Pub. No. 23-0046.
https://psnet.ahrq.gov/issue/national-healthcare-quality-and-disparities-report-chartbook-patient-safety-0
The Network of Pati…
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psnet.ahrq.gov/node/35501/psn-pdf
June 15, 2011 - Ethical issues in patient safety.
June 15, 2011
Leape L. Ethical issues in patient safety. Thorac Surg Clin. 2005;15(4):493-501.
https://psnet.ahrq.gov/issue/ethical-issues-patient-safety
This commentary, written by patient safety expert Lucian Leape, begins with a retrospective view on the
birth of patient safety…
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psnet.ahrq.gov/node/34935/psn-pdf
June 23, 2009 - Improving patient care. The cognitive psychology of
missed diagnoses.
June 23, 2009
Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med.
2005;142(2):115-120.
https://psnet.ahrq.gov/issue/improving-patient-care-cognitive-psychology-missed-diagnoses
This case study de…
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psnet.ahrq.gov/node/39086/psn-pdf
May 24, 2015 - Psychiatry morbidity and mortality rounds:
implementation and impact.
May 24, 2015
Goldman S, Demaso DR, Kemler B. Psychiatry morbidity and mortality rounds: implementation and impact.
Acad Psychiatry. 2009;33(5):383-8. doi:10.1176/appi.ap.33.5.383.
https://psnet.ahrq.gov/issue/psychiatry-morbidity-and-mortality-r…
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psnet.ahrq.gov/node/40342/psn-pdf
April 21, 2015 - Counterheroism, common knowledge, and ergonomics:
concepts from aviation that could improve patient safety.
April 21, 2015
Lewis GH, Vaithianathan R, Hockey PM, et al. Counterheroism, common knowledge, and ergonomics:
concepts from aviation that could improve patient safety. Milbank Q. 2011;89(1):4-38. doi:10.1111/…
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psnet.ahrq.gov/node/42893/psn-pdf
March 13, 2014 - Effect of patient safety strategies on the incidence of
adverse events.
March 13, 2014
Sierra AF, del Aguila del MR, Espigares JLN, et al. Effect of patient safety strategies on the incidence of
adverse events. J Eval Clin Pract. 2014;20(2):184-90. doi:10.1111/jep.12105.
https://psnet.ahrq.gov/issue/effect-patient…
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psnet.ahrq.gov/node/34927/psn-pdf
June 23, 2009 - Health Care Quality and Disparities: Lessons from the
First National Reports.
June 23, 2009
Kelley E, Moy E, Dayton E, et al. Med Care. 2005:43(3):I1-I88.
https://psnet.ahrq.gov/issue/health-care-quality-and-disparities-lessons-first-national-reports
Highlights from AHRQ's two inaugural reports, the 2003 National …
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psnet.ahrq.gov/node/44107/psn-pdf
August 15, 2016 - Patient safety and end-of-life care: common issues,
perspectives, and strategies for improving care.
August 15, 2016
Dy SM. Patient Safety and End-of-Life Care: Common Issues, Perspectives, and Strategies for Improving
Care. Am J Hosp Palliat Care. 2016;33(8):791-6. doi:10.1177/1049909115581847.
https://psnet.ahrq…
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psnet.ahrq.gov/node/47767/psn-pdf
June 12, 2019 - Gaps in ambulatory patient safety for immunosuppressive
specialty medications.
June 12, 2019
Patterson S, Schmajuk G, Evans M, et al. Gaps in Ambulatory Patient Safety for Immunosuppressive
Specialty Medications. Jt Comm J Qual Patient Saf. 2019;45(5):348-357. doi:10.1016/j.jcjq.2018.12.003.
https://psnet.ahrq.gov…