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psnet.ahrq.gov/issue/declaration-advance-patient-safety
July 12, 2017 - Book/Report
Declaration to Advance Patient Safety.
Citation Text:
Declaration to Advance Patient Safety. National Steering Committee for Patient Safety. Boston, MA: Institute for Healthcare Improvement; May 2022.
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psnet.ahrq.gov/issue/black-or-other-doctors-may-be-relying-race-make-decisions-about-your-health
September 15, 2021 - Newspaper/Magazine Article
Black or 'other'? Doctors may be relying on race to make decisions about your health.
Citation Text:
Black or 'other'? Doctors may be relying on race to make decisions about your health. Smith J, Spodak C. CNN. April 25, 2021.
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psnet.ahrq.gov/issue/state-va-health-care
May 01, 2015 - Congressional Testimony
The State of VA Health Care.
Citation Text:
The State of VA Health Care. Hearing Before the Committee on Veterans' Affairs United States Senate. 113th Cong (September 9, 2014).
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psnet.ahrq.gov/issue/transforming-health-care-compendium-reports-national-patient-safety-foundations-lucian-leape
November 23, 2016 - Book/Report
Transforming Health Care: A Compendium of Reports From the National Patient Safety Foundation's Lucian Leape Institute.
Citation Text:
Transforming Health Care: A Compendium of Reports From the National Patient Safety Foundation's Lucian Leape Institute. Boston, MA: National …
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psnet.ahrq.gov/issue/safer-dx-checklist-10-high-priority-practices-diagnostic-excellence
August 04, 2021 - Tools/Toolkit
Safer Dx Checklist: 10 High-Priority Practices for Diagnostic Excellence.
Citation Text:
Safer Dx Checklist: 10 High-Priority Practices for Diagnostic Excellence. Houston TX; Baylor College of Medicine: 2022.
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psnet.ahrq.gov/issue/closing-deaths-door-legal-innovations-end-epidemic-healthcare-harm
January 27, 2021 - Book/Report
Closing Death’s Door: Legal Innovations to End the Epidemic of Healthcare Harm.
Citation Text:
Closing Death’s Door: Legal Innovations to End the Epidemic of Healthcare Harm. Saks M, Landsman S. New York, NY: Oxford University Press; 2021. ISBN: 9780190667986.
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psnet.ahrq.gov/issue/framework-analysing-risk-and-safety-clinical-medicine
March 05, 2014 - Commentary
Classic
Framework for analysing risk and safety in clinical medicine.
Citation Text:
Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316(7138):1154-7.
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psnet.ahrq.gov/issue/hearing-patient-safety-and-quality-issues-end-stage-renal-disease-treatment
December 23, 2012 - Congressional Testimony
Hearing on Patient Safety and Quality Issues in End Stage Renal Disease Treatment.
Citation Text:
Hearing on Patient Safety and Quality Issues in End Stage Renal Disease Treatment. House Committee on Ways and Means. 109th Congress, 2nd Sess (December 6, 2006).…
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psnet.ahrq.gov/issue/medical-research-and-institutional-review-board-librarians-role-human-subject-testing
June 01, 2022 - Commentary
Medical research and the Institutional Review Board: the librarian's role in human subject testing.
Citation Text:
Medical research and the Institutional Review Board: the librarian's role in human subject testing. Robinson JG; Gehle JL. Reference Services Review. 2005;33(…
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psnet.ahrq.gov/issue/whither-challenger-wither-columbia-management-decision-making-and-knowledge-analytic
September 07, 2011 - Commentary
Whither Challenger, wither Columbia: management decision making and the knowledge analytic.
Citation Text:
Whither Challenger, wither Columbia: management decision making and the knowledge analytic. Garrett TM.
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psnet.ahrq.gov/issue/communication-devices-operating-room
December 02, 2020 - Review
Communication devices in the operating room.
Citation Text:
Ruskin KJ. Communication devices in the operating room. Curr Opin Anaesthesiol. 2006;19(6):655-9.
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psnet.ahrq.gov/issue/enacting-washington-state-patient-safety-act-requiring-hospital-staffing-plans-nursing
May 04, 2015 - Legislation/Case Law
Enacting the Washington state patient safety act requiring hospital staffing plans for nursing services and establishing recordkeeping and reporting requirements.
Citation Text:
Enacting the Washington state patient safety act requiring hospital staffing plans for n…
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psnet.ahrq.gov/issue/first-do-no-harm-improving-health-quality-and-patient-safety
September 28, 2010 - Congressional Testimony
First, Do No Harm: Improving Health Quality and Patient Safety.
Citation Text:
First, Do No Harm: Improving Health Quality and Patient Safety. Full Committee Hearing. US Senate Committee on Health, Education, Labor and Pensions (May 5, 2011)
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psnet.ahrq.gov/issue/safe-practices-better-healthcare-2006-update
September 06, 2011 - Book/Report
Safe Practices for Better Healthcare: 2006 Update.
Citation Text:
Safe Practices for Better Healthcare: 2006 Update. Washington DC: National Quality Forum; 2007.
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psnet.ahrq.gov/issue/tutorial-ahrq-sopsr-data-entry-and-analysis-tool
December 10, 2024 - Audiovisual Presentation
AHRQ’s Surveys on Patient Safety Culture® Program: An Overview for New Users.
Citation Text:
AHRQ’s Surveys on Patient Safety Culture® Program: An Overview for New Users. Rockville, MD: Agency for Healthcare Research and Quality. January 15, 2025.
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psnet.ahrq.gov/issue/medical-liability-new-ideals-making-system-work-better-patients
May 18, 2011 - Congressional Testimony
Medical Liability: New Ideals for Making the System Work Better for Patients.
Citation Text:
Medical Liability: New Ideals for Making the System Work Better for Patients. Hearing before Senate Committee on Health Education Labor and Pensions (June 22, 2006).
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psnet.ahrq.gov/issue/medical-errors-mandatory-reporting-voluntary-reporting-or-both
February 28, 2024 - Commentary
Medical errors: mandatory reporting, voluntary reporting, or both?
Citation Text:
Grepperud S. Medical Errors: Mandatory Reporting, Voluntary Reporting, or Both? European Journal of Law and Economics. 2005;20(1). doi:10.1007/s10657-005-1019-8.
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psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md
August 01, 2015 - each other, I don't think will happen on its own in that the incentives for individual health care organizations … But more needs to be done to support vendors' design innovation and for health care organization to focus … Information Exchange: The Role of Health IT Developers in Improving Patient Safety in High Reliability Organizations … Interview
In Conversation with Timothy Vogus about High Reliability Organization
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psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
February 01, 2007 - conveyed back to the original diagnostician, as patients weave their way through different health care organizations … or different silos of the same organization. … conditions within the pages of a textbook, it would actually look at the electronic medical records of an organization … Related Resources
Perspective
High Reliability Organization
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psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
May 01, 2018 - SPOTLIGHT CASE
Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency
Citation Text:
Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…