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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/47766/psn-pdf
March 27, 2019 - Advancing the Safety of Acute Pain Management.
March 27, 2019
Boston, MA: Institute for Healthcare Improvement; 2019.
https://psnet.ahrq.gov/issue/advancing-safety-acute-pain-management
Pain management has emerged as a complex safety concern. This report discusses four organizational
prerequisites to improve pain …
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psnet.ahrq.gov/node/844556/psn-pdf
February 15, 2023 - Using Machine Learning to Improve Patient Safety in the
Home or Remote Setting for Adults.
February 15, 2023
Feske-Kirby K, Whittington J, McGaffigan P. Boston, MA: Institute for Healthcare Improvement; 2022.
https://psnet.ahrq.gov/issue/using-machine-learning-improve-patient-safety-home-or-remote-setting-adults
T…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-d.pdf
October 05, 2015 - Appendix D. Poster on Indications for Urinary Catheters
AHRQ Safety Program for Reducing CAUTI in Hospitals
Appendix D. Poster on Indications for Urinary Catheters
In lower right, use Adobe Acrobat Pro to insert contact information for your institution.
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www.ahrq.gov/talkingquality/resources/initiatives.html
November 01, 2018 - Key Initiatives in Measuring and Reporting Health Care Quality
Several individual organizations and collaborative initiatives have helped to shape the national health care agenda with respect to transparency, accountability, improvement, and informed choice. Within their respective areas of focus, they have spu…
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psnet.ahrq.gov/node/855002/psn-pdf
November 01, 2023 - Temporarily holding medication orders safely in order to
prevent patient harm.
November 1, 2023
ISMP Medication Safety Alert! Acute care edition. October 19, 2023;28(21):1-4.
https://psnet.ahrq.gov/issue/temporarily-holding-medication-orders-safely-order-prevent-patient-harm
Process disconnects can cause administr…
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psnet.ahrq.gov/node/45565/psn-pdf
May 24, 2017 - Leading a Culture of Safety: a Blueprint for Success.
May 24, 2017
Chicago, IL: American College of Healthcare Executives, National Patient Safety Foundation's Lucian
Leape Institute; 2017.
https://psnet.ahrq.gov/issue/leading-culture-safety-blueprint-success
Health care leadership plays an undeniable role in sust…
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psnet.ahrq.gov/node/44946/psn-pdf
February 01, 2017 - Quality gaps identified through mortality review.
February 1, 2017
Kobewka DM, van Walraven C, Turnbull J, et al. Quality gaps identified through mortality review. BMJ Qual
Saf. 2017;26(2):141-149. doi:10.1136/bmjqs-2015-004735.
https://psnet.ahrq.gov/issue/quality-gaps-identified-through-mortality-review
Inpatien…
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psnet.ahrq.gov/node/33934/psn-pdf
March 02, 2011 - A hospitalization from hell: a patient's perspective on
quality.
March 2, 2011
Cleary PD. A hospitalization from hell: a patient's perspective on quality. Ann Intern Med. 2003;138(1):33-
39.
https://psnet.ahrq.gov/issue/hospitalization-hell-patients-perspective-quality
The author shares the unique perspectives of…
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psnet.ahrq.gov/node/47627/psn-pdf
January 16, 2019 - Safety of overlapping inpatient orthopaedic surgery: a
multicenter study.
January 16, 2019
Dy CJ, Osei DA, Maak TG, et al. Safety of Overlapping Inpatient Orthopaedic Surgery: A Multicenter Study.
J Bone Joint Surg Am. 2018;100(22):1902-1911. doi:10.2106/JBJS.17.01625.
https://psnet.ahrq.gov/issue/safety-overlappi…
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psnet.ahrq.gov/node/72762/psn-pdf
February 17, 2021 - Optimizing Health IT for Safe Integration of Behavioral
Health and Primary Care.
February 17, 2021
Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021.
https://psnet.ahrq.gov/issue/optimizing-health-it-safe-integration-behavioral-health-and-primary-care
Effective integration of hea…
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psnet.ahrq.gov/node/46069/psn-pdf
February 28, 2018 - Strategies for Creating, Sustaining, and Improving a
Culture of Safety in Health Care, Second Edition.
February 28, 2018
Joint Commission Resources. Oak Brook, IL: Joint Commission; 2017. ISBN: 9781599409474.
https://psnet.ahrq.gov/issue/strategies-creating-sustaining-and-improving-culture-safety-health-care-
seco…
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psnet.ahrq.gov/node/50867/psn-pdf
February 05, 2020 - Cognitive testing of older clinicians prior to
recredentialing.
February 5, 2020
Cooney L, Balcezak T. Cognitive Testing of Older Clinicians Prior to Recredentialing. JAMA.
2020;323(2):179-180. doi:10.1001/jama.2019.18665.
https://psnet.ahrq.gov/issue/cognitive-testing-older-clinicians-prior-recredentialing
In an…
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psnet.ahrq.gov/node/60008/psn-pdf
July 09, 2024 - IHI Patient Safety Congress.
July 9, 2024
Institute for Healthcare Improvement. San Diego, CA, March 10-11, 2025.
https://psnet.ahrq.gov/issue/ihi-patient-safety-congress
This annual conference will host pre-session workshops, panels, and presentations covering a variety of
patient safety topics that ali…
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psnet.ahrq.gov/node/43440/psn-pdf
August 13, 2014 - Hospital Experiences Using Electronic Health Records to
Support Medication Reconciliation.
August 13, 2014
Grossman JM, Gourevitch R, Cross D. Washington, DC: National Institute for Health Care Reform; July
2014. NIHCR Research Brief No. 17.
https://psnet.ahrq.gov/issue/hospital-experiences-using-electronic-health…
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psnet.ahrq.gov/node/47855/psn-pdf
June 19, 2019 - Medication Overload: America's Other Drug Problem.
June 19, 2019
Brownlee S; Garber J. Brookline, MA: Lown Institute; 2019.
https://psnet.ahrq.gov/issue/medication-overload-americas-other-drug-problem
Overprescribing is a common problem that contributes to patient harm. This report examines financial,
clinical, an…
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psnet.ahrq.gov/node/42233/psn-pdf
May 01, 2013 - From the school of nursing quality and safety officer:
nursing students' use of safety reporting tools and their
perception of safety issues in clinical settings.
May 1, 2013
Cooper E. From the school of nursing quality and safety officer: nursing students' use of safety reporting
tools and their perception of saf…
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digital.ahrq.gov/ahrq-funded-projects/empowering-cancer-patients-through-innovations-information-technology-based/final-report
January 01, 2023 - Empowering Cancer Patients Through Innovations in Information Technology-Based Reporting of Precision Medicine - Final Report
Citation
Gray S. Empowering Cancer Patients Through Innovations in Information Technology-Based Reporting of Precision Medicine - Final Report. (Prepared by Beckman Research In…
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digital.ahrq.gov/ahrq-funded-projects/designing-demographics-optimizing-usability-patient-portals/final-report
January 01, 2023 - Designing for Demographics-Optimizing the Usability of Patient Portals - Final Report
Citation
Naheed A. Designing for Demographics-Optimizing the Usability of Patient Portals - Final Report. (Prepared by MedStar Health Research Institute under Grant No. R03 HS026298). Rockville, MD: Agency for Health…
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psnet.ahrq.gov/node/38907/psn-pdf
January 03, 2017 - Applying Toyota Production System principles to a
psychiatric hospital: making transfers safer and more
timely.
January 3, 2017
Young JQ, Wachter R. Applying Toyota Production System principles to a psychiatric hospital: making
transfers safer and more timely. Jt Comm J Qual Patient Saf. 2009;35(9):439-448.
https…