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psnet.ahrq.gov/node/859353/psn-pdf
December 20, 2023 - Global State of Patient Safety 2023.
December 20, 2023
Illingworth J, Shaw A, Fernandez et al. London UK: Imperial College London; 2023.
https://psnet.ahrq.gov/issue/global-state-patient-safety-2023
Patient safety data can support learning health systems and worldwide improvement. This report discusses
a set of in…
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psnet.ahrq.gov/node/37984/psn-pdf
August 13, 2008 - Planning and implementing a systems-based patient
safety curriculum in medical education.
August 13, 2008
Thompson DA, Cowan J, Holzmueller CG, et al. Planning and implementing a systems-based patient
safety curriculum in medical education. Am J Med Qual. 2008;23(4):271-8.
doi:10.1177/1062860608317763.
https://ps…
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psnet.ahrq.gov/node/37204/psn-pdf
September 26, 2007 - Enhancing Prescription Medicine Adherence: A National
Plan.
September 26, 2007
Rockville, MD: National Council on Patient Information and Education; 2007.
https://psnet.ahrq.gov/issue/enhancing-prescription-medicine-adherence-national-plan
This report discusses poor medication adherence as a public health issue, d…
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psnet.ahrq.gov/node/42419/psn-pdf
July 17, 2013 - Health IT Patient Safety Action and Surveillance Plan.
July 17, 2013
Washington, DC: Office of the National Coordinator for Health Information Technology; July 2, 2013.
https://psnet.ahrq.gov/issue/health-it-patient-safety-action-and-surveillance-plan
This report from the Department of Health and Human Services (HH…
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psnet.ahrq.gov/node/60189/psn-pdf
April 01, 2020 - Eliminating Medication Overload: A National Action Plan.
April 1, 2020
Working Group on Medication Overload. Brookline, MA: Lown Institute; 2020.
https://psnet.ahrq.gov/issue/eliminating-medication-overload-national-action-plan
Polypharmacy and medication overuse are known contributors to patient harm. This report …
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psnet.ahrq.gov/node/40139/psn-pdf
January 22, 2017 - Standardizing hospital discharge planning at the Mayo
Clinic.
January 22, 2017
Holland DE, Hemann MA. Standardizing hospital discharge planning at the Mayo Clinic. Jt Comm J Qual
Patient Saf. 2011;37(1):29-36.
https://psnet.ahrq.gov/issue/standardizing-hospital-discharge-planning-mayo-clinic
Implementation of a s…
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psnet.ahrq.gov/node/41333/psn-pdf
April 25, 2012 - Critical Incident Reviews, Significant Adverse Event
Reports and Action Plans.
April 25, 2012
St Andrews, Scotland: Scottish Information Commissioner; February 21, 2012. Reference No: 201100433.
https://psnet.ahrq.gov/issue/critical-incident-reviews-significant-adverse-event-reports-and-action-plans
This report de…
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psnet.ahrq.gov/node/40704/psn-pdf
August 17, 2011 - Plan for quality to improve patient safety at the point of
care.
August 17, 2011
Ehrmeyer SS. Plan for Quality to Improve Patient Safety at the Point of Care. Ann Saudi Med. 2011;31(4).
doi:10.4103/0256-4947.83203.
https://psnet.ahrq.gov/issue/plan-quality-improve-patient-safety-point-care
This review discusses t…
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psnet.ahrq.gov/node/42730/psn-pdf
September 02, 2016 - Strategic Plan for Preventing and Mitigating Drug
Shortages.
September 2, 2016
Silver Spring, MD: Food and Drug Administration; October 2013.
https://psnet.ahrq.gov/issue/strategic-plan-preventing-and-mitigating-drug-shortages
This report outlines the FDA's plans to address drug shortages, including streamlining t…
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psnet.ahrq.gov/issue/high-costs-weak-compliance-new-york-state-hospital-adverse-event-reporting-and-tracking
July 22, 2020 - Book/Report
The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System.
Citation Text:
The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System. Thompson WC Jr. New York, NY: Off…
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psnet.ahrq.gov/node/37205/psn-pdf
December 14, 2007 - Health IT implementation stories: HANDS care plan tool
seeks to improve nurse communication at handoff in
AHRQ-funded study.
December 14, 2007
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/health-it-implementation-stories-hands-care-plan-tool-seeks-improve-nurse-
communication
This art…
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psnet.ahrq.gov/node/36572/psn-pdf
January 05, 2017 - Medical emergency team calls: the need to communicate
a resuscitation plan.
January 5, 2017
MacPartlin M, Hillman KM. Medical emergency team calls: the need to communicate a resuscitation plan.
Jt Comm J Qual Patient Saf. 2007;33(1):54-6, 1.
https://psnet.ahrq.gov/issue/medical-emergency-team-calls-need-communicat…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
August 01, 2009 - Spotlight Case July 2008
Spotlight Case
Nurse Staffing Ratios:
The Crucible of Money, Policy, Research, and Patient Care
*
Source and Credits
This presentation is based on the August 2009 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME/CEU credit is available
Commentary by: …
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psnet.ahrq.gov/node/42357/psn-pdf
December 04, 2016 - Disclosing medical mistakes: a communication
management plan for physicians.
December 4, 2016
Petronio S, Torke A, Bosslet G, et al. Disclosing medical mistakes: a communication management plan for
physicians. Perm J. 2013;17(2):73-9. doi:10.7812/TPP/12-106.
https://psnet.ahrq.gov/issue/disclosing-medical-mistakes…
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psnet.ahrq.gov/node/60242/psn-pdf
March 01, 2021 - Team-Developed Care Plan and Ongoing Care
Management by Social Workers and Nurse Practitioners
Result in Better Outcomes and Reduced Acute Care
Utilization in Low-Income Seniors and other High-Risk
Populations
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovatio…
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psnet.ahrq.gov/node/837192/psn-pdf
May 25, 2022 - Declaration to Advance Patient Safety.
May 25, 2022
National Steering Committee for Patient Safety. Boston, MA: Institute for Healthcare Improvement; May
2022.
https://psnet.ahrq.gov/issue/declaration-advance-patient-safety
Leadership commitment is crucial to attaining sustainable improvement in patient safety. Th…
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psnet.ahrq.gov/node/41293/psn-pdf
June 01, 2012 - Developing an action plan for patient radiation safety in
adult cardiovascular medicine.
June 1, 2012
Douglas PS, Carr J, Cerqueira MD, et al. Developing an action plan for patient radiation safety in adult
cardiovascular medicine: proceedings from the Duke University Clinical Research Institute/American
College o…
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psnet.ahrq.gov/node/35186/psn-pdf
July 13, 2005 - Saving lives: hospitals have signed on to a six-part plan
to avoid a multitude of unnecessary deaths.
July 13, 2005
Comarow A. US News & World Report. July 2005
https://psnet.ahrq.gov/issue/saving-lives-hospitals-have-signed-six-part-plan-avoid-multitude-unnecessary-
deaths
This article, accompanying the widely r…
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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - Cardiothoracic Surgery, Trauma Surgery, and Orthopedics discussed this high-risk case extensively and ultimately planned
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psnet.ahrq.gov/node/47085/psn-pdf
June 06, 2018 - Medical Device Safety Action Plan: Protecting Patients,
Promoting Public Health.
June 6, 2018
Silver Spring, MD: US Food and Drug Administration; April 2018.
https://psnet.ahrq.gov/issue/medical-device-safety-action-plan-protecting-patients-promoting-public-health
Reliable use of medical devices is an important co…