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psnet.ahrq.gov/issue/injection-practices-among-clinicians-united-states-health-care-settings
January 06, 2017 - A national prospective cohort study. … August 3, 2022
National estimates of insulin-related hypoglycemia and errors leading … January 12, 2022
Preventability and causes of readmissions in a national cohort of general … Strategies to Improve Safety for People Who Use Substances
October 30, 2024
National … Healthcare Quality and Disparities Reports.
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psnet.ahrq.gov/issue/reversing-rise-maternal-mortality
January 18, 2017 - enhancements in collecting data on maternal health outcomes, access to care, understanding of racial disparities … , accountability, and listening to patients and families who have been impacted by unsafe maternal … January 18, 2017
A perinatal care quality and safety initiative: are there financial … May 22, 2019
Recommendations from a national panel on quality improvement in obstetrics … December 9, 2015
The Report of the Morecambe Bay Investigation.
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psnet.ahrq.gov/issue/economic-evaluation-quality-improvement-interventions-prevent-catheter-associated-urinary
January 25, 2017 - July 14, 2021
Systematic review and meta-analysis of interventions for operating room … June 8, 2022
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National Healthcare Quality … and Disparities Reports. … December 9, 2015
Implementing a national program to reduce catheter-associated urinary … October 31, 2014
Eliminating CLABSI: A National Patient Safety Imperative.
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psnet.ahrq.gov/issue/morbidity-and-mortality-caused-noncompliance-california-hospital-licensure-immediate
May 19, 2021 - Study
Morbidity and mortality caused by noncompliance with California hospital licensure … September 21, 2022
Relationships between pediatric safety indicators across a national … Medication safety in mental health hospitals: a mixed-methods analysis of incidents reported to the National … Reporting and Learning System. … January 24, 2024
National Healthcare Quality and Disparities Reports.
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psnet.ahrq.gov/issue/drug-shortage-associated-increase-catheter-related-blood-stream-infection-children
April 24, 2018 - National drug shortages have increased and emerged as a serious patient safety issue in the United … This evidence illustrates profound financial and patient safety implications related to a national drug … February 13, 2014
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National Healthcare … Quality and Disparities Reports. … July 31, 2013
Eliminating CLABSI: A National Patient Safety Imperative.
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psnet.ahrq.gov/issue/consumermedsafetyorg
April 12, 2019 - This redesigned Web site provides information about drug safety alerts and allows consumers to help … report and prevent medication errors. … January 26, 2023
Deep Dive: Racial and Ethnic Disparities in Health and Healthcare. … August 14, 2019
ISMP QuarterWatch Reports. … April 12, 2019
National Patient Safety Agency (NPSA).
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psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-adults
April 10, 2024 - ethnic disparities, and poor quality of care. … families seeking care to compare the quality of care in settings like hospitals and NHs, among others … lower quality of care. 39,40 Unfortunately, segregation has been a historic structural problem in NHs … NHs and pointed out some potential gaps in the survey processes meant to insure quality of care. … Association of nursing home ratings on health inspections, quality of care, and nurse staffing with COVID
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psnet.ahrq.gov/issue/fostering-transparency-outcomes-quality-safety-and-costs
January 29, 2015 - The lack of effective quality and safety measures hinders health care improvement and transparency … Health system leaders' role in addressing racism: time to prioritize eliminating health care disparities … September 24, 2017
National hospital ratings systems share few common scores and may … November 2, 2018
Gross Negligence Manslaughter in Healthcare: The Report of a Rapid Policy … Annual Report 2017.
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psnet.ahrq.gov/issue/us-inaction-lets-look-alike-tubes-kill-patients
September 01, 2008 - (s)
WebM&M Cases
Empiric Steroids: the Good, the Bad, and … September 1, 2008
Improving patient safety with team coordination: challenges and … Investigation of urology intraoperative events leading to root cause analysis at national … June 19, 2007
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National Healthcare Quality … and Disparities Reports.
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psnet.ahrq.gov/issue/systematic-review-application-plan-do-study-act-method-improve-quality-healthcare
May 01, 2019 - systematic review of the plan-do-study-act method of quality improvement showed that most studies do not report … incidents in endoscopy: a human factors analysis of non-procedural significant harm incidents from the National … Reporting and Learning System (NRLS). … August 14, 2013
The Measurement and Monitoring of Safety. … May 8, 2013
Explaining ethnic disparities in patient safety: a qualitative analysis.
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psnet.ahrq.gov/issue/why-your-doctors-white-coat-can-be-threat-your-health
November 18, 2016 - Healthcare Personnel Attire and Devices as Fomites: A Systematic Review. … This newspaper article reports on how clinician attire , stethoscopes, and technology can be contaminated … catheter-associated infections: results of two national collaboratives. … March 31, 2021
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National Healthcare … Quality and Disparities Reports.
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psnet.ahrq.gov/issue/state-wide-initiative-standardize-compounding-oral-liquids-pediatrics
January 23, 2017 - January 23, 2017
Communicating certainty in pathology reports: interpretation differences … May 13, 2024
MHA and MHA Keystone Center Annual Reports. … January 1, 2022
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National Healthcare … Quality and Disparities Reports. … , and initiatives improve the outcome?
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psnet.ahrq.gov/issue/reviewing-methodologically-disparate-data-practical-guide-patient-safety-research-field
April 24, 2018 - implementation project: the impact of variable WHO checklist compliance on risk-adjusted clinical outcomes after national … January 19, 2016
Patient safety skills in primary care: a national survey of GP educators … A review of challenges and solutions. … systematic review and meta-analysis. … May 25, 2016
Human factors and ergonomics and quality improvement science: integrating
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psnet.ahrq.gov/issue/bias-and-racism-teaching-rounds-academic-medical-center
August 12, 2020 - Implicit and explicit bias can reduce the effectiveness and safety of care. … national survey. … : application of the socioecological model to reduce racial disparities in the NICU. … March 8, 2023
Health disparities: impact of health disparities and treatment decision-making … April 14, 2017
Unequal Treatment: Confronting Racial and Ethnic Disparities in Health
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psnet.ahrq.gov/issue/safe-use-health-information-technology
December 23, 2016 - December 23, 2016
Eliminating racial and ethnic disparities causing mortality and morbidity … August 7, 2019
Diagnostic overshadowing among groups experiencing health disparities. … June 29, 2022
Addressing health care disparities by improving quality and safety. … 2016
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Enhancing patient safety: a national … HIT vendors, their customers, and patients: a report of an AMIA special task force.
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psnet.ahrq.gov/issue/hear-her-concerns
April 01, 2024 - National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health; … Share
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April 6, 2022
National … National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health; … August 10, 2022
Final Report of the Ockenden Review. … April 27, 2022
Using the ecological systems theory to understand black/white disparities
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psnet.ahrq.gov/Information/Panel
January 01, 2012 - In this role, she oversees all quality of care and regulatory programs for the health plan and provider … Clark Foundation, which has reduced disparities in maternal and infant mortality in Washington, DC. … In addition, she contributes her research expertise in disparities, health equity, and patient safety … to the initiative to uncover the contributing factors leading to disparities in maternal and infant … After her father died from medical errors, she has become a patient advocate promoting quality of care
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psnet.ahrq.gov/issue/nosocomial-infection-deficit-reduction-act-and-incentives-hospitals
September 14, 2011 - course for health professions and related sciences students. … February 1, 2023
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Related Resources
National Healthcare … Quality and Disparities Reports. … December 12, 2014
Healthcare-associated infections: a national patient safety problem … and the coordinated response.
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psnet.ahrq.gov/issue/disparate-perspectives-exploring-healthcare-professionals-misaligned-mental-models-older
May 11, 2022 - , and the organization. … 2021
Organizational readiness to change as a leverage point for improving safety: a national … August 7, 2019
Bedside shift report improves patient safety and nurse accountability. … View More
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psnet.ahrq.gov/issue/weekend-effect-hospital-mortality-ischemic-and-hemorrhagic-stroke-us-rural-and-urban
January 19, 2022 - reactions using safety event reports across hospitals. … July 15, 2020
Changes in weekend and weekday care quality of emergency medical admissions … to 20 hospitals in England during implementation of the 7-day services national health policy. … April 20, 2022
Racial disparities in preventable adverse events attributed to poor care … coordination reported in a national study of older US adults.