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psnet.ahrq.gov/node/44016/psn-pdf
November 21, 2016 - Partnering to Improve Quality and Safety: A Framework
for Working With Patient and Family Advisors.
November 21, 2016
Chicago, IL: Health Research & Educational Trust; 2015.
https://psnet.ahrq.gov/issue/partnering-improve-quality-and-safety-framework-working-patient-and-family-
advisors
Patient and family advisor…
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psnet.ahrq.gov/node/72643/psn-pdf
January 13, 2021 - Ockenden Report. Emerging Fndings and
Recommendations from the Independent Review of
Maternity Services at the Shrewsbury and Telford
Hospital NHS Trust.
January 13, 2021
London UK: Crown Copyright; December 10, 2020. ISBN: 9781528623049.
https://psnet.ahrq.gov/issue/ockenden-report-emerging-fndings-a…
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psnet.ahrq.gov/node/73418/psn-pdf
June 23, 2021 - Evaluation of older persons' medications: a critical
incident technique study exploring healthcare
professionals' experiences and actions.
June 23, 2021
Holmqvist M, Thor J, Ros A, et al. Evaluation of older persons’ medications: a critical incident technique
study exploring healthcare professionals’ experiences a…
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psnet.ahrq.gov/node/47132/psn-pdf
June 28, 2018 - National Steering Committee for Patient Safety.
June 28, 2018
Agency for Healthcare Research and Quality and the Institute for Healthcare Improvement.
https://psnet.ahrq.gov/issue/national-steering-committee-patient-safety
Preventable patient harm is a global public health concern. This announcement highlights a ne…
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psnet.ahrq.gov/node/47142/psn-pdf
June 13, 2018 - Managing health IT risks: reflections and
recommendations.
June 13, 2018
Sujan M. Managing health IT risks: reflections and recommendations. J Innov Health Inform.
2018;25(1):952. doi:10.14236/jhi.v25i1.952.
https://psnet.ahrq.gov/issue/managing-health-it-risks-reflections-and-recommendations
Health information t…
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psnet.ahrq.gov/node/857060/psn-pdf
November 27, 2023 - edn11
maintain a commitment to introducing a culture of safety and cultivating mutually beneficial partnerships
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psnet.ahrq.gov/node/854262/psn-pdf
October 04, 2023 - Five strategies for how patients and families can improve
patient safety: World Patient Safety Day 2023.
October 4, 2023
Wu AW, Papieva I, Sheridan S, et al. Five strategies for how patients and families can improve patient
safety: World Patient Safety Day 2023. J Patient Saf Risk Manag. 2023;28(4):147-152.
doi:10…
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psnet.ahrq.gov/node/73705/psn-pdf
September 15, 2021 - Do patient engagement interventions work for all
patients? A systematic review and realist synthesis of
interventions to enhance patient safety.
September 15, 2021
Newman B, Joseph K, Chauhan A, et al. Do patient engagement interventions work for all patients? A
systematic review and realist synthesis of intervent…
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psnet.ahrq.gov/node/33755/psn-pdf
September 01, 2013 - What We've Learned About Leveraging Leadership and
Culture to Affect Change and Improve Patient Safety
September 1, 2013
Singer SJ. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve
Patient Safety. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/what-weve-learned-ab…
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psnet.ahrq.gov/node/33904/psn-pdf
January 25, 2016 - Healthcare Cost and Utilization Project (HCUP).
January 25, 2016
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/healthcare-cost-and-utilization-project-hcup
The Healthcare Cost and Utilization Project (HCUP) is a family of databases and related software tools and
products developed throug…
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psnet.ahrq.gov/node/60906/psn-pdf
August 18, 2021 - Global Patient Safety Action Plan 2021-2030: Towards
Eliminating Avoidable Harm in Health Care.
August 18, 2021
Geneva, Switzerland: World Health Organization; 2021. ISBN: 9789240032705.
https://psnet.ahrq.gov/issue/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-
harm-health-care
The Wo…
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psnet.ahrq.gov/node/61004/psn-pdf
October 07, 2020 - National Nursing Home COVID Action Network.
October 7, 2020
Rockville, MD: Agency for Healthcare Research and Quality; September 2020.
https://psnet.ahrq.gov/issue/national-nursing-home-covid-action-network
Nursing home residents are especially vulnerable to COVID-19 due to their age, and communal living
condition…
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psnet.ahrq.gov/node/44213/psn-pdf
July 08, 2015 - The role of patients and their relatives in 'speaking up'
about their own safety—a qualitative study of acute
illness.
July 8, 2015
Rainey H, Ehrich K, Mackintosh N, et al. The role of patients and their relatives in 'speaking up' about their
own safety - a qualitative study of acute illness. Health Expect. 2015;1…
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psnet.ahrq.gov/node/49869/psn-pdf
July 02, 2019 - Failure to Rescue the Mother
July 2, 2019
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/failure-rescue-mother
The Case
A 27-year-old woman, G5 P2 A2, was first admitted to the hospital at 25 weeks of pregnancy for vaginal
bleeding. An …
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psnet.ahrq.gov/node/44664/psn-pdf
May 30, 2016 - Ventilator-related adverse events: a taxonomy and
findings from 3 incident reporting systems.
May 30, 2016
Pham JC, Williams TL, Sparnon EM, et al. Ventilator-Related Adverse Events: A Taxonomy and Findings
From 3 Incident Reporting Systems. Respir Care. 2016;61(5):621-31. doi:10.4187/respcare.04151.
https://psnet…
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psnet.ahrq.gov/node/850342/psn-pdf
June 14, 2023 - Eliminating central line associated bloodstream infections
in pediatric oncology patients: a quality improvement
effort.
June 14, 2023
Willis DN, Looper K, Malone RA, et al. Eliminating central line associated bloodstream infections in
pediatric oncology patients: a quality improvement effort. Pediatr Qual Saf. 20…
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psnet.ahrq.gov/node/47787/psn-pdf
February 20, 2019 - How to be a very safe maternity unit: an ethnographic
study.
February 20, 2019
Liberati EG, Tarrant C, Willars J, et al. How to be a very safe maternity unit: An ethnographic study. Soc
Sci Med. 2019;223:64-72. doi:10.1016/j.socscimed.2019.01.035.
https://psnet.ahrq.gov/issue/how-be-very-safe-maternity-unit-ethnog…
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psnet.ahrq.gov/node/44276/psn-pdf
July 08, 2015 - 2014 Guide to State Adverse Event Reporting Systems.
July 8, 2015
Hanlon C, Sheedy K, Kniffin T, Rosenthal J. Portland, ME: National Academy for State Health Policy; 2015.
https://psnet.ahrq.gov/issue/2014-guide-state-adverse-event-reporting-systems
State reporting systems were advocated early in the patient safety…
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psnet.ahrq.gov/node/33765/psn-pdf
April 01, 2014 - Where I see those
partnerships occurring, I've seen just incredible innovation and effectiveness. … more involved directly with the health care system that we can see
more of those kinds of productive partnerships
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psnet.ahrq.gov/node/33803/psn-pdf
January 01, 2015 - We must constantly pay
attention to partnerships and try to ensure that the evidence is understood and