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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42238/psn-pdf
    July 02, 2014 - Teaching medical error disclosure to physicians-in- training: a scoping review. July 2, 2014 Stroud L, Wong BM, Hollenberg E, et al. Teaching medical error disclosure to physicians-in-training: a scoping review. Acad Med. 2013;88(6):884-92. doi:10.1097/ACM.0b013e31828f898f. https://psnet.ahrq.gov/issue/teaching-me…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61122/psn-pdf
    January 01, 2022 - Implementing high-reliability organization principles into practice: a rapid evidence review. November 11, 2020 Veazie S, Peterson K, Bourne D, et al. Implementing high-reliability organization principles into practice: a rapid evidence review. J Patient Saf. 2022;18(1):e320-e328. doi:10.1097/pts.0000000000000768. …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44246/psn-pdf
    November 15, 2016 - RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. November 15, 2016 Boston, MA: National Patient Safety Foundation; 2015. https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm The National Patient Safety Foundation issued these guidelines for improving root cause a…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/859350/psn-pdf
    December 20, 2023 - What are the experiences of team members involved in root cause analysis? A qualitative study. December 20, 2023 Willis R, Jones T, Hoiles J, et al. What are the experiences of team members involved in root cause analysis? A qualitative study. BMC Health Serv Res. 2023;23(1):1152. doi:10.1186/s12913-023-10164-9. h…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43496/psn-pdf
    November 01, 2016 - Designing and Delivering Whole-Person Transitional Care: Hospital Guide to Reducing Medicaid Readmissions. November 1, 2016 Boutwell A, Bourgoin A , Maxwell J, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0047-EF. https://psnet.ahrq.gov/issue/designing-…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853064/psn-pdf
    August 30, 2023 - Barriers and facilitators to implementing interventions for reducing avoidable hospital readmission: systematic review of qualitative studies. August 30, 2023 Fu BQ, Zhong CCW, Wong CHL, et al. Barriers and facilitators to implementing interventions for reducing avoidable hospital readmission: systematic review of…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34642/psn-pdf
    June 24, 2015 - Human factor in cardiac surgery: errors and near misses in a high technology medical domain. June 24, 2015 Carthey J, de Leval MR, Reason JT. The human factor in cardiac surgery: errors and near misses in a high technology medical domain. Ann Thorac Surg. 2001;72(1):300-5. https://psnet.ahrq.gov/issue/human-factor…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851921/psn-pdf
    August 02, 2023 - Association between electronic health record implementations and hospital-acquired conditions in pediatric hospitals. August 2, 2023 Rabbani N, Pageler NM, Hoffman JM, et al. Association between electronic health record implementations and hospital-acquired conditions in pediatric hospitals. Appl Clin Inform. 2023…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50779/psn-pdf
    January 08, 2020 - STOPP/START criteria for potentially inappropriate medications/potential prescribing omissions in older people: origin and progress. January 8, 2020 O’Mahony D. STOPP/START criteria for potentially inappropriate medications/potential prescribing omissions in older people: origin and progress. Expert Rev Clin Pharm…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60660/psn-pdf
    July 09, 2020 - Pharmacist-led program to improve transitions from acute care to skilled nursing facility care. July 9, 2020 Achilleos M, McEwen J, Hoesly M, et al. Pharmacist-led program to improve transitions from acute care to skilled nursing facility care. Am J Health Syst Pharm. 2020;77(12). doi:10.1093/ajhp/zxaa090. https:/…

  11. Toolkit Modules | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/mvp/modules.html
    January 01, 2017 - Toolkit Modules The toolkit consists of four modules and other resources that will help ICUs uncover local defects, implement interventions to prevent ventilator-associated events, and build a sustainable safety culture. Module on How To Apply CUSP for Mechanically Ventilated Patients The Comprehensive Unit…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866938/psn-pdf
    October 09, 2024 - The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception towards Co-Design. October 9, 2024 Epstein HM, Haskell H, Hemmelgarn C, et al. The Patient’s Role In Diagnostic Safety And Excellence: From Passive Reception Towards Co-Design. Rockville, MD: Agency for Healthcare Research and Quality; …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34707/psn-pdf
    September 29, 2017 - National Patient Safety Foundation agenda for research and development in patient safety. September 29, 2017 Cooper JB, Gaba DM, Liang B, et al. The National Patient Safety Foundation agenda for research and development in patient safety. MedGenMed. 2000;2(3):E38. https://psnet.ahrq.gov/issue/national-patient-safe…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838917/psn-pdf
    October 26, 2022 - The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy. October 26, 2022 Kanter MH, Ghobadi A, Lurvey LD, et al. The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy. Diagnosis (Berl). 2022;9(4):430-436. doi:10.1515/dx-2022-0083. https:/…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852269/psn-pdf
    August 09, 2023 - Implementation of barcode medication administration (BMCA) technology on infusion pumps in the operating rooms. August 9, 2023 Hogerwaard M, Stolk M, Dijk L van, et al. Implementation of barcode medication administration (BMCA) technology on infusion pumps in the operating rooms. BMJ Open Qual. 2023;12(2):e002023.…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47853/psn-pdf
    April 10, 2019 - Does a unit shift report "blackout" period improve patient safety? April 10, 2019 Olmstead J. Does a unit shift report "blackout" period improve patient safety? Nurs Manage. 2019;50(3):8- 10. doi:10.1097/01.NUMA.0000553500.85897.51. https://psnet.ahrq.gov/issue/does-unit-shift-report-blackout-period-improve-patien…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45362/psn-pdf
    January 23, 2017 - Capturing essential information to achieve safe interoperability. January 23, 2017 Weininger S, Jaffe MB, Rausch T, et al. Capturing Essential Information to Achieve Safe Interoperability. Anesth Analg. 2017;124(1):83-94. https://psnet.ahrq.gov/issue/capturing-essential-information-achieve-safe-interoperability T…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42287/psn-pdf
    November 26, 2014 - What do patients think about year-end resident continuity clinic handoffs?: a qualitative study. November 26, 2014 Pincavage A, Lee WW, Beiting KJ, et al. What do patients think about year-end resident continuity clinic handoffs? A qualitative study. J Gen Intern Med. 2013;28(8):999-1007. doi:10.1007/s11606-013-239…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44837/psn-pdf
    February 03, 2016 - Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study). February 3, 2016 Phatak A, Prusi R, Ward B, et al. Impact of pharmacist involvement in the transitional care of high-risk patients t…

  20. Action Plan Worksheet (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/action-plan-template.docx
    June 02, 2025 - Action Plan Worksheet ACTION PLAN WORKSHEET INSTRUCTIONS: 1. Discuss with your team some improvements you’d like to make specific to the High Leverage Changes listed in the table. Use the data from the Quality Improvement Change Assessment (QICA), current patient panel data, discussions with your coach and team, or ob…
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