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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…
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psnet.ahrq.gov/issue/systematic-systems-analysis-practical-approach-patient-safety-reviews
October 27, 2015 - Book/Report
Systematic Systems Analysis: A Practical Approach to Patient Safety Reviews.
Citation Text:
Systematic Systems Analysis: A Practical Approach to Patient Safety Reviews. Duchscherer C, Davies JM. Calgary, Alberta, Canada: Health Quality Council of Alberta; 2012.
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psnet.ahrq.gov/issue/telemedicine-ensuring-safe-equitable-person-centered-virtual-care
March 29, 2006 - Book/Report
Telemedicine: Ensuring Safe, Equitable, Person-Centered Virtual Care.
Citation Text:
Telemedicine: Ensuring Safe, Equitable, Person-Centered Virtual Care. Perry AF, Federico F, Huebner J. Boston, MA: Institute for Healthcare Improvement; 2021.
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psnet.ahrq.gov/issue/patient-safety-hospitals-face-challenges-implementing-evidence-based-practices
September 07, 2016 - Book/Report
Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices.
Citation Text:
Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices. Washington, DC: United States Government Accountability Office; February 2016. Publication GAO-16-3…
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psnet.ahrq.gov/issue/ahrq-health-literacy-universal-precautions-toolkit-2nd-edition
April 30, 2008 - Toolkit
AHRQ Health Literacy Universal Precautions Toolkit. 3rd edition.
Citation Text:
AHRQ Health Literacy Universal Precautions Toolkit. 3rd edition. Brach C, ed. Rockville, MD: Agency for Healthcare Research and Quality; March 2024. AHRQ Publication No. 15-0023-EF.
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psnet.ahrq.gov/issue/community-living-centers-va-needs-strengthen-its-approach-addressing-resident-complaints
October 12, 2022 - Book/Report
Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints.
Citation Text:
Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints. Washington, DC: United States Government Accountability Office; N…
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psnet.ahrq.gov/issue/preventing-errors-when-preparing-and-administering-medications-enteral-feeding-tubes
November 30, 2016 - Newspaper/Magazine Article
Preventing errors when preparing and administering medications via enteral feeding tubes.
Citation Text:
Preventing errors when preparing and administering medications via enteral feeding tubes. ISMP Medication Safety Alert! Acute care edition. November 17, 202…
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psnet.ahrq.gov/issue/there-no-such-thing-nonjudgmental-debriefing-theory-and-method-debriefing-good-judgment
December 19, 2014 - Commentary
There is no such thing as a "nonjudgmental" debriefing: a theory and method for debriefing with good judgment.
Citation Text:
Rudolph JW, Simon R, Dufresne RL, et al. There's no such thing as "nonjudgmental" debriefing: a theory and method for debriefing with good judgment. Si…
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psnet.ahrq.gov/issue/using-medical-malpractice-closed-claims-data-reduce-surgical-risk-and-improve-patient-safety
December 01, 2010 - Commentary
Using medical malpractice closed claims data to reduce surgical risk and improve patient safety.
Citation Text:
Manuel BM, Greenwald LM. Using medical malpractice closed claims data to reduce surgical risk and improve patient safety. Bull Am Coll Surg. 2007;92(3):27-30.
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psnet.ahrq.gov/issue/piece-my-mind-im-sorry
November 22, 2017 - Commentary
A piece of my mind. I'm sorry.
Citation Text:
Kahn JS. A PIECE OF MY MIND. I'm Sorry. JAMA. 2015;313(24):2427-8. doi:10.1001/jama.2014.6507.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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digital.ahrq.gov/ahrq-funded-projects/improving-health-information-technology-implementation-rural-health-system
January 01, 2023 - Improving Health Information Technology Implementation in a Rural Health System
Project Final Report ( PDF , 871.19 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily re…
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psnet.ahrq.gov/issue/selected-medication-safety-risks-manage-2016-might-otherwise-fall-radar-screen-part-1-and
March 09, 2016 - Newspaper/Magazine Article
Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2.
Citation Text:
Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2. ISMP Medicat…
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psnet.ahrq.gov/issue/perfusion-safety-new-initiatives-and-enduring-principles
July 19, 2023 - Commentary
Perfusion safety: new initiatives and enduring principles.
Citation Text:
Kurusz M. Perfusion safety: new initiatives and enduring principles. Perfusion. 2011;26 Suppl 1:6-14. doi:10.1177/0267659110393389.
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psnet.ahrq.gov/issue/health-literacy-and-patient-safety-events
January 11, 2017 - Newspaper/Magazine Article
Health literacy and patient safety events.
Citation Text:
Gardner LA. Health literacy and patient safety events. PA-PSRS Patient Saf Advis. 2016;13(2):58-65.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…
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psnet.ahrq.gov/issue/alarm-management-promoting-safety-and-establishing-guidelines
May 24, 2017 - Commentary
Alarm management: promoting safety and establishing guidelines.
Citation Text:
Criscitelli T. Alarm Management: Promoting Safety and Establishing Guidelines. AORN J. 2016;103(5):518-21. doi:10.1016/j.aorn.2016.03.008.
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Format:
DOI Google Scholar PubM…
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psnet.ahrq.gov/issue/cultures-caring-healthcare-scandals-inquiries-and-remaking-accountabilities
September 07, 2022 - Commentary
Cultures of caring: healthcare 'scandals', inquiries, and the remaking of accountabilities.
Citation Text:
Goodwin D. Cultures of caring: Healthcare 'scandals', inquiries, and the remaking of accountabilities. Soc Stud Sci. 2018;48(1):101-124. doi:10.1177/0306312717751051.
C…
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psnet.ahrq.gov/issue/government-and-industry-fail-protect-public-when-they-suggest-carefully-following
February 24, 2016 - Newspaper/Magazine Article
Government and industry fail to protect the public when they suggest "carefully following instructions" is enough to prevent vaccine errors.
Citation Text:
Government and industry fail to protect the public when they suggest "carefully following instructions" i…
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psnet.ahrq.gov/issue/administration-concentrated-potassium-chloride-injection-during-code-still-deadly
May 02, 2018 - Newspaper/Magazine Article
Administration of concentrated potassium chloride for injection during a code: still deadly!
Citation Text:
Administration of concentrated potassium chloride for injection during a code: still deadly! ISMP Medication Safety Alert! Acute care edition. June …
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/ambulatory/6bb-toolkit-acronyms.pdf
June 02, 2025 - Acronyms and Terms
Acronyms and Terms
The following acronyms and terms are used throughout the Six Building Blocks How-To-Implement
Toolkit.
• 42 CFR: 42 Code of Federal Regulations Part 2 regulations have been put in place to protect
patient confidentiality related to treatment for substance use di…
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psnet.ahrq.gov/issue/dod-should-improve-its-process-clinical-adverse-actions-against-providers
May 16, 2018 - Book/Report
DOD Should Improve Its Process for Clinical Adverse Actions against Providers.
Citation Text:
DOD Should Improve Its Process for Clinical Adverse Actions against Providers. Washington, DC: United States Government Accounting Office; April 11, 2024. Publication GAO-24-106107.
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