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psnet.ahrq.gov/node/41246/psn-pdf
April 06, 2012 - Utilizing improvement science methods to improve
physician compliance with proper hand hygiene.
April 6, 2012
White CM, Statile AM, Conway PH, et al. Utilizing improvement science methods to improve physician
compliance with proper hand hygiene. Pediatrics. 2012;129(4):e1042-50. doi:10.1542/peds.2011-1864.
https:/…
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psnet.ahrq.gov/node/764413/psn-pdf
March 02, 2022 - Telemedicine: Ensuring Safe, Equitable, Person-Centered
Virtual Care.
March 2, 2022
Perry AF, Federico F, Huebner J. Boston, MA: Institute for Healthcare Improvement; 2021.
https://psnet.ahrq.gov/issue/telemedicine-ensuring-safe-equitable-person-centered-virtual-care
The emergence of telemedicine during…
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psnet.ahrq.gov/node/47220/psn-pdf
September 12, 2018 - Strategically Advancing Patient and Family Advisory
Councils in New York State Hospitals.
September 12, 2018
Bethesda, MD: Institute for Patient- and Family-Centered Care; June 2018.
https://psnet.ahrq.gov/issue/strategically-advancing-patient-and-family-advisory-councils-new-york-state-
hospitals
Hospital patien…
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psnet.ahrq.gov/node/60285/psn-pdf
April 29, 2020 - How Collective Design Triumphed Over Competition in
the Fight Against HAIs.
April 29, 2020
Wilson T. St Louis, MO; Facilities Guidelines Institute; 2020.
https://psnet.ahrq.gov/issue/how-collective-design-triumphed-over-competition-fight-against-hais
Health care environment design can affect safety. This report sh…
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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/40883/psn-pdf
February 10, 2012 - Consensus statement on effective communication of
urgent diagnoses and significant, unexpected diagnoses
in surgical pathology and cytopathology from the College
of American Pathologists and Association of Directors of
Anatomic and Surgical Pathology.
February 10, 2012
Nakhleh RE, Myers JL, Allen TC, et al. Conse…
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psnet.ahrq.gov/node/72511/psn-pdf
November 25, 2020 - Hospital Preparedness for a COVID-19 Surge:
Assessment Tool.
November 25, 2020
Boston, MA: Institute for Healthcare Improvement; 2020.
https://psnet.ahrq.gov/issue/hospital-preparedness-covid-19-surge-assessment-tool
Hospital crisis management, preparation, and planning are of heightened interest due to the …
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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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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/37422/psn-pdf
March 23, 2011 - Educational quality improvement report: outcomes from a
revised morbidity and mortality format that emphasised
patient safety.
March 23, 2011
Bechtold ML, Scott SD, Nelson K, et al. Educational quality improvement report: outcomes from a revised
morbidity and mortality format that emphasised patient safety. Qual S…
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psnet.ahrq.gov/node/42625/psn-pdf
November 08, 2013 - Miscount incidents: a novel approach to exploring risk
factors for unintentionally retained surgical items.
November 8, 2013
Judson TJ, Howell MD, Guglielmi C, et al. Miscount incidents: a novel approach to exploring risk factors for
unintentionally retained surgical items. Jt Comm J Qual Patient Saf. 2013;39(10):4…
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psnet.ahrq.gov/node/35383/psn-pdf
January 02, 2017 - North Mississippi Medical Center: a focus on quality,
safety, and financial critical success factors.
January 2, 2017
Murphree J, Englert J, Koch K, et al. North Mississippi Medical Center: a focus on quality, safety, and
financial critical success factors. Jt Comm J Qual Patient Saf. 2005;31(10):545-53.
https://p…
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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/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/72733/psn-pdf
February 10, 2021 - Start the year off right by preventing these top 10
medication errors and hazards from 2020.
February 10, 2021
ISMP Medication Safety Alert! Acute care edition. January 27, 2021;26(2).
https://psnet.ahrq.gov/issue/start-year-right-preventing-these-top-10-medication-errors-and-hazards-2020
Medication safety is chal…
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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/864865/psn-pdf
March 20, 2024 - The Top Five: A Review of Post-Pandemic Patient Safety
Priorities.
March 20, 2024
Sacramento, CA: Hospital Quality Institute; 2024.
https://psnet.ahrq.gov/issue/top-five-review-post-pandemic-patient-safety-priorities
The COVID pandemic posed wide-ranging challenges to both society at large as well as to the health…
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psnet.ahrq.gov/node/34570/psn-pdf
March 07, 2005 - Measuring the Success of the Regional Medication Safety
Program for Hospitals.
March 7, 2005
Pelczarski K, Fricker M, Morris J. Philadelphia, PA: Health Care Improvement Foundation; 2005.
https://psnet.ahrq.gov/issue/measuring-success-regional-medication-safety-program-hospitals
The Regional Medication Safety Prog…
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psnet.ahrq.gov/node/60555/psn-pdf
January 01, 2021 - Putting the patient in patient safety investigations:
barriers and strategies for involvement.
June 3, 2020
Busch IM, Saxena A, Wu AW. Putting the patient in patient safety investigations: barriers and strategies for
involvement. J Patient Saf. 2021;17(5):358-362. doi:10.1097/pts.0000000000000699.
https://psnet.ah…
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psnet.ahrq.gov/node/43399/psn-pdf
August 06, 2014 - Pediatric medication administration errors and workflow
following implementation of a bar code medication
administration system.
August 6, 2014
Hardmeier A, Tsourounis C, Moore M, et al. Pediatric medication administration errors and workflow
following implementation of a bar code medication administration system.…