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psnet.ahrq.gov/node/44343/psn-pdf
July 22, 2015 - including
raising awareness of the problem, enhancing team communication, and designing alarm management
initiatives
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psnet.ahrq.gov/node/38459/psn-pdf
October 03, 2012 - The authors advocate for a combination of educational initiatives, performance data, explicit
accountabilities
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psnet.ahrq.gov/node/44359/psn-pdf
January 06, 2016 - discusses insights from a health system that, due to restructuring,
found various transition improvement initiatives
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psnet.ahrq.gov/node/43316/psn-pdf
July 02, 2014 - Exploring
factors that hinder safety during transitions, this review describes successful improvement initiatives
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psnet.ahrq.gov/node/43234/psn-pdf
June 04, 2014 - challenges related to nurses performing double checks and human factors elements
to consider when designing initiatives
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psnet.ahrq.gov/node/38600/psn-pdf
October 03, 2017 - programmes
Through analyzing studies that evaluated cost, efficiency, and effectiveness of patient safety initiatives
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psnet.ahrq.gov/issue/jcaho-launch-global-patient-safety-center-initial-focus-will-be-reviewing-and-publicizing
December 22, 2010 - Newspaper/Magazine Article
JCAHO to launch global patient safety center: the initial focus will be on reviewing and publicizing research findings.
Citation Text:
JCAHO to launch global patient safety center: the initial focus will be on reviewing and publicizing research findings. Robezn…
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psnet.ahrq.gov/node/50645/psn-pdf
November 06, 2019 - FDA Funding Available for Research Aimed at Reducing
Preventable Harm from Medication
November 6, 2019
Silver Spring, MD; US Food and Drug Administration: October 4, 2019.
https://psnet.ahrq.gov/issue/fda-funding-available-research-aimed-reducing-preventable-harm-medication
Medication error is a persistent challen…
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psnet.ahrq.gov/node/35068/psn-pdf
September 21, 2005 - Cleveland Clinic Health System: a comprehensive
framework for a health system patient safety initiative.
September 21, 2005
Nadzam DM; Atkins PM; Waggoner DM; Shonk R.
https://psnet.ahrq.gov/issue/cleveland-clinic-health-system-comprehensive-framework-health-system-
patient-safety
The authors describe seven strat…
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psnet.ahrq.gov/cme
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations A man with a history of prior umbilical hernia repair presented to the emergency department (ED) with abdominal pain and was initially diagnosed with cholelithiasis before being discharged home. However, the next day he returned to …
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psnet.ahrq.gov/node/38085/psn-pdf
September 08, 2010 - Diagnostic errors and temporal stability in bipolar
disorder.
September 8, 2010
López J, Baca E, Botillo C, et al. [Diagnostic errors and temporal stability in bipolar disorder]. Actas Esp
Psiquiatr. 2008;36(4):205-9.
https://psnet.ahrq.gov/issue/diagnostic-errors-and-temporal-stability-bipolar-disorder
This stud…
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psnet.ahrq.gov/node/49563/psn-pdf
May 01, 2008 - Is It Safe to Be Direct?
May 1, 2008
Kulkarni NS, Williams M. Is It Safe to Be Direct? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/it-safe-be-direct
The Case
A 92-year-old man with hypertension and heart failure (HF) was evaluated by his primary care physician
(PCP) for progressive shortness of breat…
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psnet.ahrq.gov/node/38602/psn-pdf
January 14, 2025 - World Hand Hygiene Day.
January 14, 2025
World Health Organization
https://psnet.ahrq.gov/issue/save-lives-clean-your-hands
This global initiative raises awareness about hand hygiene as a strategy to reduce health care–associated
infections. The initiative highlights Save Lives: Clean Your Hands, an annual promoti…
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psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework-reducing-inpatient-harm
February 26, 2025 - The NQP team works with each LifePoint hospital to assess their current performance, existing initiatives
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psnet.ahrq.gov/web-mm/it-safe-be-direct
September 30, 2015 - Is It Safe to Be Direct?
Citation Text:
Kulkarni NS, Williams M. Is It Safe to Be Direct?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…
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psnet.ahrq.gov/node/837813/psn-pdf
January 21, 2021 - Recognizing Excellence in Diagnosis.
January 21, 2021
The Leapfrog Group.
https://psnet.ahrq.gov/issue/recognizing-excellence-diagnosis
Examination of diagnostic failure and identification of reduction strategies require multidisciplinary expertise
to be successful. This collaborative initiative will initially dev…
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psnet.ahrq.gov/node/866343/psn-pdf
December 31, 2024 - Mismanagement of Acute Decompensated Heart Failure
with Hypertensive Emergency
December 31, 2024
Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive
Emergency. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hyperte…
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psnet.ahrq.gov/node/42858/psn-pdf
January 15, 2014 - Early access to a neurologist reduces the rate of missed
diagnosis in young strokes.
January 15, 2014
Mohamed W, Bhattacharya P, Chaturvedi S. Early access to a neurologist reduces the rate of missed
diagnosis in young strokes. J Stroke Cerebrovasc Dis. 2013;22(8):e332-7.
doi:10.1016/j.jstrokecerebrovasdis.2013.01…
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psnet.ahrq.gov/node/60627/psn-pdf
June 24, 2020 - Second opinions improve healthcare outcomes and
reduce costs.
June 24, 2020
Hébert AR. Second opinions improve healthcare outcomes and reduce costs. Employee Benefit News.
2020;June 8.
https://psnet.ahrq.gov/issue/second-opinions-improve-healthcare-outcomes-and-reduce-costs
Second opinions are a strategy for redu…
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psnet.ahrq.gov/issue/health-it-hazard-manager
August 01, 2012 - Government Resource
Health IT Hazard Manager.
Citation Text:
Health IT Hazard Manager. Rockville, MD: Agency for Healthcare Research and Quality. AHRQ Publication No. 12-0058-EF May 2012.
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