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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45383/psn-pdf
    August 31, 2016 - Case report of a medication error: in the eye of the beholder. August 31, 2016 Naunton M, Nor K, Bartholomaeus A, et al. Case report of a medication error. Medicine (Baltimore). 2016;95(28):e4186. doi:10.1097/md.0000000000004186. https://psnet.ahrq.gov/issue/case-report-medication-error-eye-beholder Look-alike dr…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46710/psn-pdf
    January 30, 2018 - Bias in radiology: the how and why of misses and misinterpretations. January 30, 2018 Busby LP, Courtier JL, Glastonbury CM. Bias in Radiology: The How and Why of Misses and Misinterpretations. Radiographics. 2018;38(1):236-247. doi:10.1148/rg.2018170107. https://psnet.ahrq.gov/issue/bias-radiology-how-and-why-mis…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43333/psn-pdf
    January 15, 2017 - A multidisciplinary, multifaceted improvement initiative to eliminate mislabelled laboratory specimens at a large tertiary care hospital. January 15, 2017 Seferian EG, Jamal S, Clark K, et al. A multidisciplinary, multifaceted improvement initiative to eliminate mislabelled laboratory specimens at a large tertiary…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46159/psn-pdf
    May 31, 2017 - Despite technology, verbal orders persist, read back is not widespread, and errors continue. May 31, 2017 ISMP Medication Safety Alert! Acute Care Edition. May 18, 2017;22:1-4. https://psnet.ahrq.gov/issue/despite-technology-verbal-orders-persist-read-back-not-widespread-and- errors-continue Verbal orders are kno…

  5. Using Data to Reduce Disparities and Improve Quality | Agency for Healthcare Research and Quality

    www.ahrq.gov/evidencenow/tools/reduce-disparities.html
    February 01, 2025 - Using Data to Reduce Disparities and Improve Quality Resource: Using Data to Reduce Disparities and Improve Quality: A Guide for Health Care Organizations (PDF, 1 MB; 14 pages) This brief recommends strategies that primary care practices and health care organizations can use to effectively organize and inter…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34786/psn-pdf
    March 28, 2005 - Errors in drug computations during newborn intensive care. March 28, 2005 Perlstein PH, Callison C, White M, et al. Errors in Drug Computations During Newborn Intensive Care. Arch Pediatr Adolesc Med. 1979;133(4):376-379. doi:10.1001/archpedi.1979.02130040030006. https://psnet.ahrq.gov/issue/errors-drug-computatio…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44724/psn-pdf
    November 25, 2015 - What's in your kit? A safety checkup may be in order. November 25, 2015 Paparella S. What's In Your Kit? A Safety Checkup May Be In Order. Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Association. 2015;41(6):513-5. doi:10.1016/j.jen.2015.07.001. https://psnet.ahrq.gov…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47038/psn-pdf
    July 18, 2018 - Delivering Quality Health Services: A Global Imperative for Universal Health Coverage. July 18, 2018 Geneva, Switzerland: World Health Organization; July 2018. ISBN: 9789241513906. https://psnet.ahrq.gov/issue/delivering-quality-health-services-global-imperative-universal-health-coverage The Crossing the Quality C…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47165/psn-pdf
    June 13, 2018 - Changing how we think about healthcare improvement. June 13, 2018 Braithwaite J. Changing how we think about healthcare improvement. BMJ. 2018;361:k2014. doi:10.1136/bmj.k2014. https://psnet.ahrq.gov/issue/changing-how-we-think-about-healthcare-improvement In learning organizations, leadership behavior creates a s…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60589/psn-pdf
    June 23, 2020 - Medication Safety During the COVID-19 Pandemic: What Have We Learned in the United States. June 23, 2020 Institute for Safe Medication Practices and US Food and Drug Administration Division of Drug Information. June 23, 2020. https://psnet.ahrq.gov/issue/medication-safety-during-covid-19-pandemic-what-have-we-lear…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47872/psn-pdf
    March 27, 2019 - Overview of the Environmental Scan of Primary Care- Based Effort To Reduce Readmissions. March 27, 2019 Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF. https://psnet.ahrq.gov/issue/overview-environmental-scan-primar…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42134/psn-pdf
    July 16, 2013 - Developing and pilot testing practical measures of preanalytic surgical specimen identification defects. July 16, 2013 Bixenstine PJ, Zarbo RJ, Holzmueller CG, et al. Developing and pilot testing practical measures of preanalytic surgical specimen identification defects. Am J Med Qual. 2013;28(4):308-14. doi:10.11…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74218/psn-pdf
    January 25, 2022 - We Can’t Do This Alone! The Role That Patients, Family Members, and the General Public Play in Advancing Patient Safety. December 22, 2021 Patient Safety Movement Foundation. January 25, 2022. https://psnet.ahrq.gov/issue/we-cant-do-alone-role-patients-family-members-and-general-public-play- advancing-patient Su…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47662/psn-pdf
    February 21, 2024 - Lucian Leape Patient Safety Fellowship Award. February 21, 2024 International Society for Quality in Health Care https://psnet.ahrq.gov/issue/lucian-leape-patient-safety-fellowship-award Inspired by the work and leadership of Dr. Lucian Leape, this award is a mentoring program to develop physicians and leaders see…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44326/psn-pdf
    October 21, 2015 - Safety first! Using a checklist for intrafacility transport of adult intensive care patients. October 21, 2015 Comeau OY, Armendariz-Batiste J, Woodby SA. Safety First! Using a Checklist for Intrafacility Transport of Adult Intensive Care Patients. Crit Care Nurse. 2015;35(5):16-25. doi:10.4037/ccn2015991. https:/…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44516/psn-pdf
    June 10, 2018 - Managing hospitalized patients with ambulatory pumps: findings from an ISMP survey—Part 1. June 10, 2018 ISMP Medication Safety Alert! Acute care edition. November 19, 2015;20(23):1-5. https://psnet.ahrq.gov/issue/managing-hospitalized-patients-ambulatory-pumps-findings-ismp-survey-part-1 Infusion therapies are in…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46025/psn-pdf
    July 11, 2017 - Measuring to improve medication reconciliation in a large subspecialty outpatient practice. July 11, 2017 Kern E, Dingae MB, Langmack EL, et al. Measuring to Improve Medication Reconciliation in a Large Subspecialty Outpatient Practice. Jt Comm J Qual Patient Saf. 2017;43(5):212-223. doi:10.1016/j.jcjq.2017.02.005…

  18. Improving Hospital Discharge Through Medication Reconciliation and Education | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/resources/discharge/index.html
    December 01, 2017 - Improving Hospital Discharge Through Medication Reconciliation and Education Project focused on improving the hospital discharge process. Mark Williams, M.D., Emory University, Atlanta, GA AHRQ Grant No. HS015882-01 Overview This project implements a "discharge bundle" consisting of medication reconcilia…

  19. Synthesizing the Outputs of Deliberative Forum (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/delilberative-methods-design-abelson-2.pdf
    May 29, 2025 - Synthesizing the Outputs of Deliberative Forum Synthesizing the Outputs of Deliberative Forum Julia Abelson, PhD Department of Clinical Epidemiology & Biostatistics McMaster University Hamilton, Ontario CANADA Slide 27 Linking deliberation objectives to outputs  What is the expected deliverable of th…

  20. Professional Education and Training in Shared Decision Making | Agency for Healthcare Research and Quality

    www.ahrq.gov/sdm/education-training/index.html
    October 01, 2024 - Professional Education and Training in Shared Decision Making Most healthcare professionals have not been taught how to engage patients in shared decision making (SDM). For SDM to become widespread, SDM skills have to be learned and practiced. AHRQ has developed education and training programs that teach SDM sk…
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