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psnet.ahrq.gov/node/60297/psn-pdf
January 01, 2021 - A call for the application of patient safety culture in
medical humanitarian action: a literature review.
May 6, 2020
Biquet J-M, Schopper D, Sprumont D, et al. A call for the application of patient safety culture in medical
humanitarian action: a literature review. J Patient Saf. 2021;17(8):e1732-e1737.
doi:10.10…
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psnet.ahrq.gov/node/42686/psn-pdf
April 16, 2019 - Improving the quality of health care: what's taking so
long?
April 16, 2019
Chassin MR. Improving The Quality Of Health Care: What’s Taking So Long? Health Aff.
2013;32(10):1761-1765. doi:10.1377/hlthaff.2013.0809.
https://psnet.ahrq.gov/issue/improving-quality-health-care-whats-taking-so-long
Almost a decade-and…
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psnet.ahrq.gov/node/40806/psn-pdf
October 31, 2011 - How best to measure surgical quality? Comparison of the
Agency for Healthcare Research and Quality Patient
Safety Indicators (AHRQ-PSI) and the American College of
Surgeons National Surgical Quality Improvement Program
(ACS-NSQIP) postoperative adverse events at a single
institution.
October 31, 2011
Cima RR, La…
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psnet.ahrq.gov/node/46739/psn-pdf
January 24, 2019 - Symptom–Disease Pair Analysis of Diagnostic Error
(SPADE): a conceptual framework and methodological
approach for unearthing misdiagnosis-related harms
using big data.
January 24, 2019
Liberman AL, Newman-Toker DE. Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): a
conceptual framework and methodologica…
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psnet.ahrq.gov/node/45605/psn-pdf
November 30, 2016 - Advancing interprofessional patient safety education for
medical, nursing, and pharmacy learners during clinical
rotations.
November 30, 2016
Thom KA, Heil EL, Croft LD, et al. Advancing interprofessional patient safety education for medical,
nursing, and pharmacy learners during clinical rotations. J Interprof Ca…
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psnet.ahrq.gov/node/45322/psn-pdf
July 20, 2016 - RN assessments of excellent quality of care and patient
safety are associated with significantly lower odds of 30-
day inpatient mortality: a national cross-sectional study
of acute-care hospitals.
July 20, 2016
Smeds-Alenius L, Tishelman C, Lindqvist R, et al. RN assessments of excellent quality of care and patie…
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psnet.ahrq.gov/node/73709/psn-pdf
September 15, 2021 - Crisis management for surgical teams and their leaders,
lessons from the COVID-19 pandemic; a structured
approach to developing resilience or natural
organisational responses.
September 15, 2021
Pring ET, Malietzis G, Kendall SWH, et al. Crisis management for surgical teams and their leaders, lessons
from the COV…
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psnet.ahrq.gov/node/46372/psn-pdf
September 13, 2017 - Impact of a successful speaking up program on health-
care worker hand hygiene behavior.
September 13, 2017
Linam MW; Honeycutt MD; Gilliam CH; Wisdom CM; Deshpande JK.
https://psnet.ahrq.gov/issue/impact-successful-speaking-program-health-care-worker-hand-hygiene-
behavior
Improving hand hygiene in health care f…
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psnet.ahrq.gov/node/37659/psn-pdf
March 02, 2011 - Universal surveillance for methicillin-resistant
Staphylococcus aureus in 3 affiliated hospitals.
March 2, 2011
Robicsek A, Beaumont JL, Paule SM, et al. Universal surveillance for methicillin-resistant Staphylococcus
aureus in 3 affiliated hospitals. Ann Intern Med. 2008;148(6):409-18.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/866962/psn-pdf
October 16, 2024 - Diagnostic Excellence– Age-Friendly Health Systems
(DxEx–AFHS) Seed Grant Program Improving Diagnosis
for Older Adults.
October 16, 2024
Boston, MA: Institute for Healthcare Improvement; September 23, 2024.
https://psnet.ahrq.gov/issue/diagnostic-excellence-age-friendly-health-systems-dxex-afhs-seed-grant-
progra…
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psnet.ahrq.gov/node/50889/psn-pdf
February 12, 2020 - Unscheduled radiologic examination orders in the
electronic health record: a novel resource for targeting
ambulatory diagnostic errors in radiology.
February 12, 2020
Lacson R, Healey MJ, Cochon LR, et al. Unscheduled Radiologic Examination Orders in the Electronic
Health Record: A Novel Resource for Targeting Amb…
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psnet.ahrq.gov/node/850910/psn-pdf
June 21, 2023 - Developing electronic clinical quality measures to assess
the cancer diagnostic process.
June 21, 2023
Murphy DR, Zimolzak AJ, Upadhyay DK, et al. Developing electronic clinical quality measures to assess
the cancer diagnostic process. J Am Med Inform Assoc. 2023;30(9):1526-1531.
doi:10.1093/jamia/ocad089.
https:…
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psnet.ahrq.gov/node/47690/psn-pdf
March 13, 2019 - I-PASS mentored implementation handoff curriculum:
champion training materials.
March 13, 2019
O'Toole JK, Starmer AJ, Calaman S, et al. I-PASS Mentored Implementation Handoff Curriculum:
Champion Training Materials. MedEdPORTAL. 2019;15:10794. doi:10.15766/mep_2374-8265.10794.
https://psnet.ahrq.gov/issue/i-pass-…
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psnet.ahrq.gov/node/37022/psn-pdf
September 24, 2010 - Implementation and impact of a rapid response team in a
children's hospital.
September 24, 2010
Zenker P, Schlesinger A, Hauck M, et al. Implementation and impact of a rapid response team in a
children's hospital. Jt Comm J Qual Patient Saf. 2007;33(7):418-425.
https://psnet.ahrq.gov/issue/implementation-and-impac…
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psnet.ahrq.gov/node/764405/psn-pdf
March 02, 2022 - Evaluation of communication and safety behaviors during
hospital-wide code response simulation.
March 2, 2022
Ren DM, Abrams A, Banigan M, et al. Evaluation of communication and safety behaviors during hospital-
wide code response simulation. Simul Healthc. 2022;17(1):e45-e50. doi:10.1097/sih.0000000000000575.
htt…
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psnet.ahrq.gov/node/73616/psn-pdf
August 18, 2021 - Do Black and White Patients Experience Similar Rates of
Adverse Safety Events at the Same Hospital?
August 18, 2021
Gangopadhyaya A. Washington DC; Urban Institute: July 2021.
https://psnet.ahrq.gov/issue/do-black-and-white-patients-experience-similar-rates-adverse-safety-events-
same-hospital
Racial inequities h…
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psnet.ahrq.gov/node/46255/psn-pdf
September 06, 2017 - Patient Safety in the Home: Assessment of Issues,
Challenges, and Opportunities.
September 6, 2017
Carpenter D, Famolaro T, Hassell S, et al. Cambridge, MA: Institute for Healthcare Improvement; 2017.
https://psnet.ahrq.gov/issue/patient-safety-home-assessment-issues-challenges-and-opportunities
The ambulatory env…
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psnet.ahrq.gov/node/47523/psn-pdf
December 05, 2018 - Developing standardized "receiver-driven" handoffs
between referring providers and the emergency
department: results of a multidisciplinary needs
assessment.
December 5, 2018
Huth K, Stack AM, Chi G, et al. Developing Standardized "Receiver-Driven" Handoffs Between Referring
Providers and the Emergency Department…
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psnet.ahrq.gov/node/73062/psn-pdf
January 01, 2022 - Description of the role of pharmacist independent double
checks during cognitive order verification of outpatient
parenteral anti-cancer therapy.
March 25, 2021
Booth JP, Kennerly-Shah JM, Hartman AD. Description of the role of pharmacist independent double
checks during cognitive order verification of outpatient …
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psnet.ahrq.gov/node/41186/psn-pdf
January 03, 2017 - The costs of adverse drug events in community hospitals.
January 3, 2017
Hug BL, Keohane C, Seger DL, et al. The costs of adverse drug events in community hospitals. Jt Comm J
Qual Patient Saf. 2012;38(3):120-6.
https://psnet.ahrq.gov/issue/costs-adverse-drug-events-community-hospitals
Adverse drug events (ADEs) a…