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psnet.ahrq.gov/issue/patient-safety-climate-strength-concept-requires-more-attention
March 04, 2011 - Study
Patient safety climate strength: a concept that requires more attention.
Citation Text:
Ginsburg LR, Oore DG. Patient safety climate strength: a concept that requires more attention. BMJ Qual Saf. 2016;25(9):680-7. doi:10.1136/bmjqs-2015-004150.
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psnet.ahrq.gov/issue/implementation-hand-hygiene-health-care-facilities-results-who-hand-hygiene-self-assessment
September 09, 2020 - Study
Implementation of hand hygiene in health-care facilities: results from the WHO Hand Hygiene Self-Assessment Framework global survey 2019.
Citation Text:
de Kraker MEA, Tartari E, Tomczyk S, et al. Implementation of hand hygiene in health-care facilities: results from the WHO Hand H…
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psnet.ahrq.gov/issue/what-stops-hospital-clinical-staff-following-protocols-analysis-incidence-and-factors-behind
September 09, 2015 - Study
What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service.
Citation Text:
Shearer B, Marshal…
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psnet.ahrq.gov/issue/leaders-and-followers-individual-experiences-during-early-phase-simulation-based-team
January 18, 2011 - Study
Leaders' and followers' individual experiences during the early phase of simulation-based team training: an exploratory study.
Citation Text:
Meurling L, Hedman L, Felländer-Tsai L, et al. Leaders' and followers' individual experiences during the early phase of simulation-based t…
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psnet.ahrq.gov/issue/medication-errors-associated-code-situations-us-hospitals-direct-and-collateral-damage
June 29, 2011 - Study
Medication errors associated with code situations in U.S. hospitals: direct and collateral damage.
Citation Text:
Lipshutz AKM, Morlock LL, Shore AD, et al. Medication Errors Associated with Code Situations in U.S. Hospitals: Direct and Collateral Damage. Jt Comm J Qual Patient Saf…
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psnet.ahrq.gov/issue/health-economic-evaluation-infection-prevention-and-control-program-are-quality-and-patient
June 02, 2021 - Study
Health economic evaluation of an infection prevention and control program: are quality and patient safety programs worth the investment?
Citation Text:
Raschka S, Dempster L, Bryce E. Health economic evaluation of an infection prevention and control program: are quality and patien…
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psnet.ahrq.gov/issue/feasibility-and-added-value-executive-walkrounds-long-term-care-organizations-netherlands
January 07, 2015 - Study
Feasibility and added value of Executive WalkRounds in long term care organizations in the Netherlands.
Citation Text:
van Dusseldorp L, de Waal GH-, Hamers H, et al. Feasibility and Added Value of Executive WalkRounds in Long Term Care Organizations in the Netherlands. Jt Comm J Q…
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psnet.ahrq.gov/issue/association-surgical-task-during-training-team-skill-acquisition-among-surgical-residents
March 12, 2025 - Study
Association of a surgical task during training with team skill acquisition among surgical residents: the missing piece in multidisciplinary team training.
Citation Text:
Sparks JL, Crouch DL, Sobba K, et al. Association of a Surgical Task During Training With Team Skill Acquisition…
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psnet.ahrq.gov/issue/program-prevent-catheter-associated-urinary-tract-infection-acute-care
December 21, 2017 - Study
Classic
A program to prevent catheter-associated urinary tract infection in acute care.
Citation Text:
Saint S, Greene T, Krein SL, et al. A Program to Prevent Catheter-Associated Urinary Tract Infection in Acute Care. New Engl J Med. 2016;374(22):2111-211…
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psnet.ahrq.gov/issue/efficiency-and-thoroughness-trade-offs-high-volume-organisational-routines-ethnographic-study
June 14, 2017 - Study
Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of prescribing safety in primary care.
Citation Text:
Grant S, Guthrie B. Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of pre…
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psnet.ahrq.gov/issue/can-patient-involvement-improve-patient-safety-cluster-randomised-control-trial-patient
December 21, 2016 - Study
Classic
Can patient involvement improve patient safety? A cluster randomised control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention.
Citation Text:
Lawton R, O'Hara JK, Sheard L, et al. Can patient involvement improve…
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psnet.ahrq.gov/node/74226/psn-pdf
February 01, 2019 - Effective implementation of the initiative also requires the participation of multidisciplinary teams
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psnet.ahrq.gov/node/837658/psn-pdf
July 08, 2022 - Preventable Transfer to the Hospital
July 8, 2022
Agrawal G, Kashkouli P, Bakerjian D. Preventable Transfer to the Hospital. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/preventable-transfer-hospital
The Case
A 78-year-old veteran with dementia-associated aggressive behavior and multiple comorbidities had…
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psnet.ahrq.gov/node/33661/psn-pdf
December 01, 2007 - Care Transitions
December 1, 2007
Kripalani S. Care Transitions. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/care-transitions
Perspective
Hospital discharge is often viewed as the end of an acute medical event. Goodbyes are said as patients
pack their belongings and return home. Physicians scratch …
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psnet.ahrq.gov/node/33624/psn-pdf
December 01, 2005 - In Conversation with…Troyen A. Brennan, MD, JD, MPH
December 1, 2005
In Conversation with…Troyen A. Brennan, MD, JD, MPH. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withtroyen-brennan-md-jd-mph
Dr. Robert Wachter, Editor, AHRQ WebM&M: What got you interested in the law and its interface…
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psnet.ahrq.gov/periodic-issue/periodic-issue-473
March 25, 2025 - March 5, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/training-catalog
June 01, 2025 - Training Catalog
The AHRQ PSNet Training Catalog is an easy to use resource for healthcare professionals across all settings of care and specialties looking for education opportunities to further their knowledge of patient safety practices and principles. Some training opportunities are available as in-person meeting…
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psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
May 01, 2012 - Situational Awareness and Patient Safety
Citation Text:
Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/issue/comparing-catheter-associated-urinary-tract-infection-prevention-programs-between-veterans
December 21, 2017 - Study
Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing homes and non–Veterans Affairs nursing homes.
Citation Text:
Mody L, Greene T, Saint S, et al. Comparing Catheter-Associated Urinary Tract Infection Prevention Programs Betwee…
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psnet.ahrq.gov/node/73102/psn-pdf
July 01, 2022 - Care Managers Use Software-Aided Medication Review
Protocol for Frail, Community-Dwelling Seniors, Leading
to More Appropriate Medication Use
March 31, 2021
https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-
community-dwelling
Summary
Care management staff (such …