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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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 …
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. 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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. 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: …
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. Psn-Pdf (pdf file)

    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…
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. 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
  20. Psn-Pdf (pdf file)

    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…

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