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psnet.ahrq.gov/node/41387/psn-pdf
May 18, 2012 - Surfing the Healthcare Tsunami: Bring Your Best Board.
May 18, 2012
Austin, TX: Texas Medical Institute for Technology; 2012.
https://psnet.ahrq.gov/issue/surfing-healthcare-tsunami-bring-your-best-board
The second in a series, this documentary focuses on learning from other high-risk industries and engaging
hospi…
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psnet.ahrq.gov/node/50767/psn-pdf
August 12, 2024 - 2024 IHI Forum
August 12, 2024
Institute for Healthcare Improvement. Orlando World Center Marriott, Orlando, FL, December 9-11, 2024.
https://psnet.ahrq.gov/issue/2024-ihi-forum
This hybrid conference will offer workshops and interactive sessions exploring strategies from within health
care and beyond to improve h…
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psnet.ahrq.gov/node/38209/psn-pdf
June 02, 2010 - The effects of emergency department staff rounding on
patient safety and satisfaction.
June 2, 2010
Meade CM, Kennedy J, Kaplan J. The effects of emergency department staff rounding on patient safety
and satisfaction. J Emerg Med. 2010;38(5):666-74. doi:10.1016/j.jemermed.2008.03.042.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/47594/psn-pdf
March 17, 2023 - Prevention of perioperative medication errors.
March 17, 2023
Nanji K. UpToDate. March 7, 2023.
https://psnet.ahrq.gov/issue/prevention-perioperative-medication-errors
Perioperative adverse drug events are common and understudied. This review examines factors that
contribute to adverse drug events in the surgical …
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psnet.ahrq.gov/node/40870/psn-pdf
October 19, 2011 - The Richard and Hinda Rosenthal Lecture 2011: New
Frontiers in Patient Safety.
October 19, 2011
Institute of Medicine. Washington, DC: The National Academies Press; 2011. ISBN: 9780309218030.
https://psnet.ahrq.gov/issue/richard-and-hinda-rosenthal-lecture-2011-new-frontiers-patient-safety
This lecture features Ka…
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psnet.ahrq.gov/training-catalog/niosh-training-nurses-shift-work-and-long-work-hours
June 23, 2025 - NIOSH Training for Nurses on Shift Work and Long Work Hours
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Organization:
Organization
National Institute for Occupational Safety and Health (…
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psnet.ahrq.gov/node/35676/psn-pdf
June 25, 2010 - Implementation of patient centeredness to enhance
patient safety.
June 25, 2010
Berntsen KJ. Implementation of patient centeredness to enhance patient safety. J Nurs Care Qual.
2006;21(1):15-19.
https://psnet.ahrq.gov/issue/implementation-patient-centeredness-enhance-patient-safety
The author reviews the six aims…
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psnet.ahrq.gov/node/37819/psn-pdf
April 14, 2010 - Standardizing Medication Labels: Confusing Patients
Less, Workshop Summary.
April 14, 2010
Hernandez LM; for Roundtable on Health Literacy, Board on Population Health and Public Health Practice,
Institute of Medicine. Washington, DC: National Academies Press; 2008.
https://psnet.ahrq.gov/issue/standardizing-medica…
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psnet.ahrq.gov/node/36146/psn-pdf
February 05, 2019 - Guidelines for Design and Construction.
February 5, 2019
St Louis, Missouri; Facilities Guidelines Institute; 2018.
https://psnet.ahrq.gov/issue/guidelines-design-and-construction
These updated guidelines include design changes, such as the adoption of private rooms to reduce
medical error, interruptions, and hosp…
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psnet.ahrq.gov/node/36922/psn-pdf
June 22, 2015 - Fluorouracil Incident Root Cause Analysis Report.
June 22, 2015
Toronto, CA: Institute for Safe Medication Practices Canada; May 2007.
https://psnet.ahrq.gov/issue/fluorouracil-incident-root-cause-analysis-report
This report shares findings from a root cause analysis of a medication error incident that led to a pat…
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psnet.ahrq.gov/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
April 01, 2010 - programs that reward individual physicians or small practices or perhaps a hospital or a health care institution
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psnet.ahrq.gov/perspective/diagnostic-errors
December 01, 2013 - position in which we may soon be able to measure the frequency of diagnostic errors in an individual institution
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psnet.ahrq.gov/node/35379/psn-pdf
June 15, 2011 - Report 6: Managing Risk and Minimising Mistakes in
Services to Children and Families.
June 15, 2011
Bostock L, Bairstow S, Fish S, et al. London, UK: Social Care Institute for Excellence; September 2005.
https://psnet.ahrq.gov/issue/report-6-managing-risk-and-minimising-mistakes-services-children-and-families
This…
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psnet.ahrq.gov/node/38248/psn-pdf
December 27, 2008 - AHRQ presses on: no rule yet, but agency taps 10 safety
organizations.
December 27, 2008
DerGurahian J. AHRQ presses on. No rule yet, but agency taps 10 safety organizations. Modern
healthcare. 2008;38(45):8-9.
https://psnet.ahrq.gov/issue/ahrq-presses-no-rule-yet-agency-taps-10-safety-organizations
This article …
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psnet.ahrq.gov/node/38518/psn-pdf
October 27, 2015 - Hospital Report Card: Ontario 2009.
October 27, 2015
Esmail N, Hazel M. Studies in Health Care Policy. Fraser Institute. Calgary, Alberta, Canada; March 2009.
ISSN: 1918-2082.
https://psnet.ahrq.gov/issue/hospital-report-card-ontario-2009
Designed to help patients choose hospitals, this report utilized AHRQ qualit…
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psnet.ahrq.gov/node/37806/psn-pdf
July 14, 2010 - Impact of patient safety mandates on medical education
in the United States.
July 14, 2010
Kane JM, Brannen ML, Kern E. Impact of Patient Safety Mandates on Medical Education in the United
States. J Patient Saf. 2008;4(2):93-97. doi:10.1097/pts.0b013e318173f7b5.
https://psnet.ahrq.gov/issue/impact-patient-safety-m…
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psnet.ahrq.gov/node/39191/psn-pdf
February 08, 2011 - Leadership in Healthcare Organizations: A Guide to Joint
Commission Leadership Standards.
February 8, 2011
Schyve PM. San Diego, CA: Governance Institute; 2009.
https://psnet.ahrq.gov/issue/leadership-healthcare-organizations-guide-joint-commission-leadership-
standards
This white paper provides comprehensive inf…
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psnet.ahrq.gov/node/47977/psn-pdf
August 14, 2019 - Reducing Diagnostic Error: Measurement Considerations.
August 14, 2019
National Quality Forum
https://psnet.ahrq.gov/issue/reducing-diagnostic-error-measurement-considerations
This website tracks the progress of a project focused on the development and review of measures to
enhance viability, reporting, accountabi…
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psnet.ahrq.gov/node/38700/psn-pdf
July 13, 2009 - The active components of effective training in obstetric
emergencies.
July 13, 2009
Siassakos D, Crofts JF, Winter C, et al. The active components of effective training in obstetric
emergencies. BJOG. 2009;116(8):1028-32. doi:10.1111/j.1471-0528.2009.02178.x.
https://psnet.ahrq.gov/issue/active-components-effectiv…
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psnet.ahrq.gov/node/60332/psn-pdf
May 13, 2020 - Circle Up Training.
May 13, 2020
Center for Medical Simulation.
https://psnet.ahrq.gov/issue/circle-training
Communication strategies are important for engaging staff in behaviors that support effective teamwork.
This website highlights a process that involves briefings, supportive conversations, and debriefings a…