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  1. High Reliability for a Highly Unreliable World: Preparing for Code Blue Through Daily Operations in Healthcare. | PSNet

    psnet.ahrq.gov/issue/high-reliability-highly-unreliable-world-preparing-code-blue-through-daily-operations
    October 09, 2013 - Book/Report High Reliability for a Highly Unreliable World: Preparing for Code Blue Through Daily Operations in Healthcare. Citation Text: High Reliability for a Highly Unreliable World: Preparing for Code Blue Through Daily Operations in Healthcare. van Stralen D, Byrum SL, Inozu B. Nor…

  2. The Joint Commission and National Quality Forum Announce 2022 Eisenberg Award Recipients. | PSNet

    psnet.ahrq.gov/issue/joint-commission-and-national-quality-forum-announce-2022-eisenberg-award-recipients
    February 21, 2024 - Award Recipient The Joint Commission and National Quality Forum Announce 2022 Eisenberg Award Recipients. Citation Text: The Joint Commission and National Quality Forum Announce 2022 Eisenberg Award Recipients. Oakbrook Terrace, IL: Joint Commission and National Quality Forum: January 23…

  3. Chase H et al. 2003 "Modem transmission of glucose values reduces the costs and need for clinic visits." | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/chase-h-et-al-2003
    January 01, 2003 - Chase H et al. 2003 "Modem transmission of glucose values reduces the costs and need for clinic visits." Reference Chase H, Pearson J, Wightman C, et al. Modem transmission of glucose values reduces the costs and need for clinic visits. Diabetes Care 2003;26(5):1475. [Link] Abstract "OBJECTI…

  4. Patient Safety and Quality Improvement Act of 2005: what you need to know. | PSNet

    psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005-what-you-need-know
    December 17, 2014 - Commentary Patient Safety and Quality Improvement Act of 2005: what you need to know. Citation Text: Rohrich RJ. Patient Safety and Quality Improvement Act of 2005: what you need to know. Plast Reconstr Surg. 2006;117(2):671-2. Copy Citation Format: Google Scholar PubMed …

  5. Medical Residents and Burnout | PSNet

    psnet.ahrq.gov/issue/medical-residents-and-burnout
    June 01, 2022 - Special or Theme Issue Medical Residents and Burnout Citation Text: Medical Residents and Burnout Coverdale J, West CP, Roberts LW, eds. Acad Med. 2021;96(5):611-769;e14-e21. Copy Citation Save Save to your library Print Download PDF Share…

  6. Pharmacy–nursing intervention to improve accuracy and completeness of medication histories. | PSNet

    psnet.ahrq.gov/issue/pharmacy-nursing-intervention-improve-accuracy-and-completeness-medication-histories
    May 29, 2014 - Commentary Pharmacy–nursing intervention to improve accuracy and completeness of medication histories. Citation Text: Tessier EG, Henneman EA, Nathanson BH, et al. Pharmacy–nursing intervention to improve accuracy and completeness of medication histories. American Journal of Health-Sys…

  7. The Value of Close Calls in Improving Patient Safety. | PSNet

    psnet.ahrq.gov/issue/value-close-calls-improving-patient-safety
    July 12, 2006 - Book/Report The Value of Close Calls in Improving Patient Safety. Citation Text: The Value of Close Calls in Improving Patient Safety. Wu AW, ed. Oakbrook Terrace, IL: Joint Commission Resources; 2011. ISBN: 9781599404158. Copy Citation Save Save to your library …

  8. The role of automation in complex system failures. | PSNet

    psnet.ahrq.gov/issue/role-automation-complex-system-failures
    June 28, 2013 - Commentary The role of automation in complex system failures. Citation Text: Perry SJ, Wears RL, Cook RI. The role of automation in complex system failures. J Patient Saf. 2005;1(1):56-61. https://journals.lww.com/journalpatientsafety/Fulltext/2005/03000/The_Role_of_Automation_in_Compl…

  9. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. | PSNet

    psnet.ahrq.gov/issue/improvement-guide-practical-approach-enhancing-organizational-performance-2nd-ed
    November 29, 2017 - Book/Report Classic The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. Citation Text: The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. Langley GJ, Moen R, Nolan KM, et al. Ho…

  10. Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. | PSNet

    psnet.ahrq.gov/issue/closing-loop-guide-safer-ambulatory-referrals-ehr-era
    July 12, 2017 - Book/Report Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. Citation Text: Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for Healthcare Imp…

  11. A nurse-driven system for improving patient quality outcomes. | PSNet

    psnet.ahrq.gov/issue/nurse-driven-system-improving-patient-quality-outcomes
    October 12, 2011 - Commentary A nurse-driven system for improving patient quality outcomes. Citation Text: Johnson K, Hallsey D, Meredith RL, et al. A nurse-driven system for improving patient quality outcomes. J Nurs Care Qual. 2006;21(2):168-175. Copy Citation Format: Google Scholar PubMe…

  12. Respectful Management of Serious Clinical Adverse Events. Second Edition. | PSNet

    psnet.ahrq.gov/issue/respectful-management-serious-clinical-adverse-events-second-edition
    January 27, 2016 - Book/Report Classic Respectful Management of Serious Clinical Adverse Events. Second Edition. Citation Text: Respectful Management of Serious Clinical Adverse Events. Second Edition. Conway J, Federico F, Stewart K, Campbell MJ. Cambridge, MA: Institute for Heal…

  13. Clinical Practice Guidelines Archive | Agency for Healthcare Research and Quality

    www.ahrq.gov/prevention/guidelines/archive.html
    July 01, 2018 - Clinical Practice Guidelines Archive The National Guideline Clearinghouse™ taken down on July 16, 2018, because federal funding though AHRQ was no longer available to support them. Please visit AHRQ's Guidelines and Measures (GAM) microsite to find information about its legacy guidelines and measures cleari…

  14. Optimizing medication safety in the home. | PSNet

    psnet.ahrq.gov/issue/optimizing-medication-safety-home
    August 24, 2015 - Study Optimizing medication safety in the home. Citation Text: LeBlanc RG, Choi J. Optimizing medication safety in the home. Home Healthc Now. 2015;33(6):313-319. doi:10.1097/NHH.0000000000000246. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote…

  15. Analysis of ISMP National Vaccine Errors Reporting Program—part 1 and part 2. | PSNet

    psnet.ahrq.gov/issue/analysis-ismp-national-vaccine-errors-reporting-program-part-1-and-part-2
    July 08, 2015 - Newspaper/Magazine Article Analysis of ISMP National Vaccine Errors Reporting Program—part 1 and part 2. Citation Text: Analysis of ISMP National Vaccine Errors Reporting Program—part 1 and part 2. ISMP Medication Safety Alert! Acute Care Edition. December 4, 2014;19:1-6. March 26, 2015;…

  16. An organizational learning framework for patient safety. | PSNet

    psnet.ahrq.gov/issue/organizational-learning-framework-patient-safety
    November 28, 2018 - Commentary An organizational learning framework for patient safety. Citation Text: Edwards MT. An Organizational Learning Framework for Patient Safety. Am J Med Qual. 2016;32(2):148-155. doi:10.1177/1062860616632295. Copy Citation Format: DOI Google Scholar BibTeX EndNote X…

  17. From Safety-I to Safety-II: A White Paper. | PSNet

    psnet.ahrq.gov/issue/safety-i-safety-ii-white-paper
    July 22, 2019 - Book/Report From Safety-I to Safety-II: A White Paper. Citation Text: From Safety-I to Safety-II: A White Paper. Hollnagel E, Wears RL, Braithwaite J. Middelfart, Denmark: Resilient Health Care Net; 2015. Copy Citation Save Save to your library Print Dow…

  18. Independent double checks: worth the effort if used judiciously and properly. | PSNet

    psnet.ahrq.gov/issue/independent-double-checks-worth-effort-if-used-judiciously-and-properly
    January 23, 2019 - Newspaper/Magazine Article Independent double checks: worth the effort if used judiciously and properly. Citation Text: Independent double checks: worth the effort if used judiciously and properly. ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24:1-7. Copy Citation …

  19. PowerPoint Presentation

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d1_combo_improvementmethodsoverview.pptx
    June 02, 2025 - PowerPoint Presentation Use these PowerPoint slides for any presentations for which they may be useful. These slides may be useful earlier on in the process than during implementation; feel free to use them at any point in your QI process. Modify as needed to suit your hospital – you may wish to delete sections of sl…

  20. HealthGrades Sixth Annual Patient Safety in American Hospitals Study. | PSNet

    psnet.ahrq.gov/issue/healthgrades-sixth-annual-patient-safety-american-hospitals-study
    October 25, 2013 - Book/Report HealthGrades Sixth Annual Patient Safety in American Hospitals Study. Citation Text: HealthGrades Sixth Annual Patient Safety in American Hospitals Study. Golden, CO: HealthGrades, Inc.; April 2009.  Copy Citation Save Save to your library …
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