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psnet.ahrq.gov/node/37450/psn-pdf
June 13, 2011 - Technical patient safety solutions for medicines
reconciliation on admission of adults to hospital.
June 13, 2011
Manchester, UK: National Institute for Health and Clinical Excellence; 2015.
https://psnet.ahrq.gov/issue/technical-patient-safety-solutions-medicines-reconciliation-admission-adults-
hospital
This gu…
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psnet.ahrq.gov/node/34718/psn-pdf
August 05, 2008 - How can we save the next victim?
August 5, 2008
Belkin L
https://psnet.ahrq.gov/issue/how-can-we-save-next-victim
In this article, Belkin examines how the medical field has recently shifted away from blaming individuals for
medical error toward a model that searches for systems problems and solutions for preventio…
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psnet.ahrq.gov/node/36883/psn-pdf
August 31, 2011 - Voluntary review of quality of care peer review for patient
safety.
August 31, 2011
Stumpf PG. Voluntary review of quality of care peer review for patient safety. Best Pract Res Clin Obstet
Gynaecol. 2007;21(4):557-64.
https://psnet.ahrq.gov/issue/voluntary-review-quality-care-peer-review-patient-safety
The autho…
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psnet.ahrq.gov/node/47053/psn-pdf
May 23, 2018 - TeamSTEPPS Canada.
May 23, 2018
Canadian Patient Safety Institute.
https://psnet.ahrq.gov/issue/teamstepps-canada
The TeamSTEPPS program was developed to support effective communication and teamwork skills in
various health care settings. This site supports the Canadian TeamSTEPPS initiative. The program will
pre…
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psnet.ahrq.gov/node/846126/psn-pdf
March 09, 2023 - For example, at our institution, when new
pharmacy personnel are hired, they are assigned online learning
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psnet.ahrq.gov/node/72614/psn-pdf
March 01, 2021 - The University of Kansas Hospital, an academic institution with
approximately 606 beds and 13 labor
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psnet.ahrq.gov/node/47262/psn-pdf
August 22, 2018 - The Case for Medication Safety Officers (MSO).
August 22, 2018
Horsham, PA: Institute for Safe Medication Practices; 2018.
https://psnet.ahrq.gov/issue/case-medication-safety-officers-mso
Medication safety is a concern in various settings across an organization. This white paper discusses the
role of a medication …
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psnet.ahrq.gov/node/43897/psn-pdf
August 21, 2015 - Guidelines for Adult IV Push Medications.
August 21, 2015
Horsham, PA: The Institute for Safe Medication Practices; July 2015.
https://psnet.ahrq.gov/issue/guidelines-adult-iv-push-medications
To address the lack of standards on intravenous (IV) push medication administration, this guidance reflects
applied expert…
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psnet.ahrq.gov/node/74069/psn-pdf
September 20, 2022 - Diagnostic Excellence.
September 20, 2022
JAMA. Nov 2021-Sep 2022.
https://psnet.ahrq.gov/issue/diagnostic-excellence-0
Diagnostic excellence achievement is becoming a primary focus in health care. This 20-article series
covers diagnosis as it relates to the Institute of Medicine quality domains, clinical ch…
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psnet.ahrq.gov/node/36778/psn-pdf
August 26, 2011 - What medications does your patient take? Enhancing
medication safety in the outpatient setting.
August 26, 2011
Institute for Healthcare Improvement; IHI
https://psnet.ahrq.gov/issue/what-medications-does-your-patient-take-enhancing-medication-safety-
outpatient-setting
This article discusses the importance of me…
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psnet.ahrq.gov/node/841489/psn-pdf
December 14, 2022 - Rise to Health Coalition.
December 14, 2022
Boston, MA; Institute for Healthcare Improvement: December 2022.
https://psnet.ahrq.gov/issue/rise-health-coalition
Systemic efforts to improve health equity support patient safety. This announcement highlights an initiative
for collective work to address four areas of e…
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psnet.ahrq.gov/node/50665/psn-pdf
November 13, 2019 - The SECOND Trial
November 13, 2019
Northwestern University Feinberg School of Medicine
https://psnet.ahrq.gov/issue/second-trial
Surgical resident well-being is paramount to ensuring safe surgical care and a healthy workforce. This
website shares information on the Surgical Education Culture Optimization through t…
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psnet.ahrq.gov/node/35034/psn-pdf
November 05, 2015 - Seven Leadership Leverage Points for Organization-Level
Improvement in Health Care. Second edition.
November 5, 2015
Reinertsen JL, Bisognano M, Pugh MD. Cambridge, MA: Institute for Healthcare Improvement; 2008.
https://psnet.ahrq.gov/issue/seven-leadership-leverage-points-organization-level-improvement-health-car…
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psnet.ahrq.gov/node/856639/psn-pdf
November 29, 2023 - Impact Wellbeing.
November 29, 2023
National Institute for Occupational Safety and Health. Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/impact-wellbeing
Clinician burnout has become a major concern for both healthcare workforce and patient safety. This portal
provides access to too…
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psnet.ahrq.gov/node/45735/psn-pdf
July 17, 2017 - CMPA Good Practices Guide.
July 17, 2017
Ottawa, Ontario: Canadian Medical Protective Association; 2016.
https://psnet.ahrq.gov/issue/cmpa-good-practices-guide
Key patient safety topics include human factors, teamwork, adverse events, communication,
professionalism, and risk management. This website provides resou…
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psnet.ahrq.gov/node/42418/psn-pdf
May 07, 2018 - Disrespectful behavior in healthcare...have we made any
progress in the last decade?
May 7, 2018
ISMP Medication Safety Alert! Acute Care Edition. June 27, 2013.
https://psnet.ahrq.gov/issue/disrespectful-behavior-healthcarehave-we-made-any-progress-last-decade
This newsletter article reviews studies that show how…
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psnet.ahrq.gov/node/35933/psn-pdf
July 26, 2010 - Surgical 'never events': how common are adverse
occurrences?
July 26, 2010
West JC. Surgical ‘never events’: How common are adverse occurrences? Journal of Healthcare Risk
Management. 2009;26(1). doi:10.1002/jhrm.5600260105.
https://psnet.ahrq.gov/issue/surgical-never-events-how-common-are-adverse-occurrences
The…
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psnet.ahrq.gov/node/41808/psn-pdf
October 08, 2024 - ISMP Medication Safety Intensive.
October 8, 2024
Institute for Safe Medication Practices. December 5-6 2024, 7:30 AM - 4:30 PM (eastern).
https://psnet.ahrq.gov/issue/ismp-medication-safety-intensive
This virtual workshop will explore tactics for community and specialty pharmacies to ensure medication
safety, inc…
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psnet.ahrq.gov/node/50662/psn-pdf
November 13, 2019 - Deep Dive: Safe Ambulatory Care, Strategies for Patient
Safety & Risk Reduction.
November 13, 2019
Plymouth Meeting, PA: ECRI Institute; 2019.
https://psnet.ahrq.gov/issue/deep-dive-safe-ambulatory-care-strategies-patient-safety-risk-reduction
Outpatient safety is gaining traction as a focal point of analysis and …
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psnet.ahrq.gov/node/47658/psn-pdf
December 12, 2018 - Heartbroken.
December 12, 2018
McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.
https://psnet.ahrq.gov/issue/heartbroken
Pediatric cardiac surgery is a high-risk practice. This news investigation reports on a series of serious
patient safety incidents at a health care institute dedicated to treating heart pr…