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psnet.ahrq.gov/issue/innovation-practice-multidisciplinary-medication-safety-initiative
August 15, 2018 - May 3, 2017
Associations between in-hospital mortality, health care utilization, and … reliability organizations: a systematic review of learning tools that could be adapted and used in healthcare … January 22, 2016
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Hospitals
Health … Care Executives and Administrators
Medicine
Administration Errors
Epidemiology of Errors and
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psnet.ahrq.gov/issue/application-failure-mode-effect-analysis-improve-care-septic-patients-admitted-through
February 01, 2013 - December 16, 2011
The impact of pharmacists-led medicines reconciliation on healthcare … February 2, 2022
Algorithmic prediction of failure modes in healthcare. … March 23, 2016
Health care failure mode and effect analysis to reduce NICU line–associated … December 18, 2014
Augmenting health care failure modes and effects analysis with simulation … Care Executives and Administrators
Safety Scientists
Emergency Medicine
Infectious Diseases
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psnet.ahrq.gov/issue/situ-simulations-detect-patient-safety-threats-during-hospital-cardiac-arrest
September 13, 2023 - polypharmacy--a qualitative study using focus group interviews with older patients, their relatives, and healthcare … July 10, 2008
Making Health Care Safer II: An Updated Critical Analysis of the Evidence
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psnet.ahrq.gov/issue/association-safety-program-improving-antibiotic-use-antibiotic-use-and-hospital-onset
July 20, 2022 - Author(s)
Assessment of changes in visits and antibiotic prescribing during the Agency for Healthcare … October 28, 2020
Impact of a hospital-wide hand hygiene initiative on healthcare-associated
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psnet.ahrq.gov/issue/health-care-quality-and-safety-correctional-system-creating-goals-and-performance-measures
May 18, 2022 - Commentary
Health care quality and safety in a correctional system: creating goals … J Correct Health Care. 2022;28(3):141-147. doi:10.1089/jchc.20.07.0058. … J Correct Health Care . 2022; 28 (3) :141-147 . … J Correct Health Care. 2022;28(3):141-147. doi:10.1089/jchc.20.07.0058. … care system: conceptual framework and initial set of actionable indicators.
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psnet.ahrq.gov/issue/review-medication-error-sources-associated-inpatient-subcutaneous-insulin-recommendations
June 17, 2020 - August 18, 2021
Overstating inpatient deaths due to medical error erodes trust in healthcare
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psnet.ahrq.gov/issue/paediatric-family-activated-rapid-response-interventions-qualitative-systematic-review
November 24, 2021 - Critical incidents involving the medical emergency team: a 5-year retrospective assessment for healthcare
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psnet.ahrq.gov/web-mm/communication-error-closed-icu
July 01, 2016 - care providers. … Health care providers often define good or bad communication as a complex process of interpersonal and … Qual Saf Health Care. 2006;15:235-239. [go to PubMed] 9. … The social construction of healthcare teams. In: Nemeth CP, ed. … Care Providers
Critical Care
Indwelling Tubes and Catheters
Active Errors
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psnet.ahrq.gov/issue/preventing-infections-how-portland-hospitals-compare
June 08, 2011 - June 8, 2011
Diagnostic Safety Across Transitions of Care Throughout the Healthcare System … March 8, 2023
What are the implications for patient safety and experience of a major healthcare … May 26, 2021
Coworker abuse in healthcare: voices of mistreated workers. … catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare
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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - errors. 3 Minimal research has investigated whether efforts to reduce communication failures across healthcare … A team of parents and healthcare professionals adapted the I-PASS framework 5 to provide a formal structure … This innovation standardized family-centered rounds and increased family and healthcare provider team … Utilizing co-production to improve patient-centeredness and engagement in healthcare delivery: lessons … Institute of Medicine Committee on Quality of Health Care in America.
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psnet.ahrq.gov/web-mm/workaround-error
October 30, 2024 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … Most health care providers are not educated about human factors issues and the potential influence of … Moreover, health care workers often overestimate their abilities and underestimate their limitations … Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services
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psnet.ahrq.gov/issue/how-hospital-leaders-contribute-patient-safety-through-development-trust
January 22, 2014 - September 24, 2016
Health care workers as second victims of medical errors. … Critical incident stress management (CISM) in complex systems: cultural adaptation and safety impacts in healthcare … June 28, 2013
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Hospitals
Health Care
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psnet.ahrq.gov/issue/medication-errors-associated-code-situations-us-hospitals-direct-and-collateral-damage
June 29, 2011 - April 8, 2011
Validity of the Agency for Healthcare Research and Quality Patient Safety
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psnet.ahrq.gov/issue/adverse-events-associated-home-blood-transfusion-retrospective-cohort-study
October 20, 2021 - Safety in home health care delivery is receiving increasing attention . … September 14, 2022
Exploring nursing-sensitive events in home healthcare: a national … collaboratives
February 26, 2020
Oral chemotherapy: a home safety educational framework for healthcare
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psnet.ahrq.gov/issue/interprofessional-learning-multidisciplinary-healthcare-teams-associated-reduced-patient
April 10, 2024 - Review
Interprofessional learning in multidisciplinary healthcare teams is associated … Interprofessional learning in multidisciplinary healthcare teams is associated with reduced patient mortality … This systematic review of quantitative evidence found that healthcare provider participation in interventions … February 23, 2022
The efficacy of mindful practice in improving diagnosis in healthcare … September 28, 2022
The Safety and Quality of Health Care: Where are We Now?
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psnet.ahrq.gov/issue/effect-hospital-command-centre-patient-safety-interrupted-time-series-study
July 20, 2022 - BMJ Health Care Inform. 2023;30(1):e100653. … BMJ Health Care Inform . 2023;30(1):e100653. … BMJ Health Care Inform. 2023;30(1):e100653. … system: results of the DEMEANOR pragmatic, cluster, cross-over trial. … system: an AMIA position paper.
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psnet.ahrq.gov/innovation/duke-pediatric-residency-safety-council
November 16, 2022 - highlights a particularly important issue and presents it in detail as a conference using the Agency for Healthcare … adverse events identified by three widely used detection methods, International Journal for Quality in Health … Care , Volume 21, Issue 4, August 2009, Pages 301–307, https://doi.org/10.1093/intqhc/mzp027
Herchline … Rockville, MD: Agency for Healthcare Research and Quality; 2008 Aug. … Department of Health and Human Services, the Agency for Healthcare Research and Quality, or of the submitter
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psnet.ahrq.gov/issue/assessment-nursing-home-reporting-major-injury-falls-quality-measurement-nursing-home-compare
August 24, 2022 - March 1, 2023
Healthcare-associated adverse events in alternate level of care patients … March 10, 2021
Unintended consequences of health care reform: impact of changes in payor
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psnet.ahrq.gov/issue/tragedy-policy-quantitative-study-nurses-attitudes-toward-patient-advocacy-activities
June 01, 2011 - and Quality
April 26, 2023
CHaMP: A model for building a center to support health … care worker well-being after experiencing an adverse event. … Annual Perspective
Annual Perspective: Psychological Safety of Healthcare
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psnet.ahrq.gov/issue/statement-prevention-retained-foreign-bodies-after-surgery
October 15, 2018 - Preventing Patient Falls: A Systematic Approach From the Joint Commission Center for Transforming Healthcare