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psnet.ahrq.gov/node/36288/psn-pdf
December 23, 2016 - Preventing adverse events caused by emergency
electrical power system failures.
December 23, 2016
Preventing adverse events caused by emergency electrical power system failures. Sentinel Event Alert.
2006;37(37):1-3.
https://psnet.ahrq.gov/issue/preventing-adverse-events-caused-emergency-electrical-power-system-
…
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psnet.ahrq.gov/node/37039/psn-pdf
September 14, 2007 - Corporate Responsibility and Health Care Quality: A
Resource for Health Care Boards of Directors.
September 14, 2007
Callender AN, Hastings DA, Hemsley MC, et al. Washington DC: Office of the Inspector General of the US
Department of Health and Human Services, American Health Lawyers Association; September 2007.
h…
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psnet.ahrq.gov/node/37017/psn-pdf
September 15, 2011 - The association between culture, climate and quality of
care in primary health care teams.
September 15, 2011
Hann M, Bower P, Campbell S, et al. The association between culture, climate and quality of care in
primary health care teams. Fam Pract. 2007;24(4):323-9.
https://psnet.ahrq.gov/issue/association-between-…
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psnet.ahrq.gov/node/35414/psn-pdf
May 21, 2014 - Assessment of the National Patient Safety Initiative:
Context and Baseline Evaluation Report 1.
May 21, 2014
Santa Monica, CA: RAND Corporation; 2005. ISBN 0833037870.
https://psnet.ahrq.gov/issue/assessment-national-patient-safety-initiative-context-and-baseline-evaluation-
report-1
The authors report on the his…
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psnet.ahrq.gov/node/37432/psn-pdf
November 29, 2009 - The Pennsylvania Learning Exchange: Helping States
Improve and Integrate Patient Safety
Initiatives—Summary Report.
November 29, 2009
Hanlon C; Rosenthal J. Portland, ME: National Academy for State Health Policy; 2007.
https://psnet.ahrq.gov/issue/pennsylvania-learning-exchange-helping-states-improve-and-integrate…
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psnet.ahrq.gov/node/73124/psn-pdf
April 07, 2021 - Safety and Quality in Perioperative Anesthesia Care.
April 7, 2021
Preckel B, ed. Best Pract Res Clin Anaesthesiol. 2021;35(1):1-154.
https://psnet.ahrq.gov/issue/safety-and-quality-perioperative-anesthesia-care
The field of anesthesiology has realized impressive improvements in safety, yet challenges still ex…
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psnet.ahrq.gov/node/38529/psn-pdf
April 01, 2009 - Standardized admission order set improves perceived
quality of pediatric inpatient care.
April 1, 2009
Bekmezian A, Chung PJ, Yazdani S. Standardized admission order set improves perceived quality of
pediatric inpatient care. J Hosp Med. 2009;4(2):90-6. doi:10.1002/jhm.403.
https://psnet.ahrq.gov/issue/standardize…
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psnet.ahrq.gov/node/35723/psn-pdf
March 28, 2011 - Impact of nursing on hospital patient mortality: a focused
review and related policy implications.
March 28, 2011
Tourangeau AE, Cranley LA, Jeffs L. Impact of nursing on hospital patient mortality: a focused review and
related policy implications. Qual Saf Health Care. 2006;15(1):4-8.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/867699/psn-pdf
June 01, 2023 - Toolkit for Improving Surgical Care and Recovery.
June 1, 2023
Agency for Healthcare Research and Quality. Toolkit for Improving Surgical Care and Recovery. June
2023.
https://psnet.ahrq.gov/issue/toolkit-improving-surgical-care-and-recovery
Improving patient experience fosters better communication, trust, and col…
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psnet.ahrq.gov/node/36050/psn-pdf
January 02, 2017 - Improving the safety of intravenous admixtures: lessons
learned from a Pentostam® overdose.
January 2, 2017
Just S, Schepers G, Piotrowski MM, et al. Improving the safety of intravenous admixtures: lessons learned
from a Pentostam overdose. Jt Comm J Qual Patient Saf. 2006;32(7):366-72.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/37934/psn-pdf
July 23, 2008 - Pediatric safety in the emergency department: identifying
risks and preparing to care for child and family.
July 23, 2008
Nadzam D, Westergaard F. Pediatric safety in the emergency department: identifying risks and preparing
to care for child and family. J Nurs Care Qual. 2008;23(3):189-194.
doi:10.1097/01.NCQ.000…
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psnet.ahrq.gov/node/38750/psn-pdf
July 01, 2009 - Probability error in diagnosis: the conjunction fallacy
among beginning medical students.
July 1, 2009
Rao G. Probability error in diagnosis: the conjunction fallacy among beginning medical students. Fam Med.
2009;41(4):262-5.
https://psnet.ahrq.gov/issue/probability-error-diagnosis-conjunction-fallacy-among-begin…
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psnet.ahrq.gov/node/43748/psn-pdf
December 03, 2014 - New enteral connectors: raising awareness.
December 3, 2014
Guenter P. New Enteral Connectors. Nutrition in Clinical Practice. 2014;29(5).
doi:10.1177/0884533614543330.
https://psnet.ahrq.gov/issue/new-enteral-connectors-raising-awareness
Redesigning tubing connectors according to new ISO standards has the potenti…
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psnet.ahrq.gov/node/37086/psn-pdf
October 03, 2011 - Failure mode and effects analysis: a useful tool for risk
identification and injury prevention.
October 3, 2011
Paparella S. Failure mode and effects analysis: a useful tool for risk identification and injury prevention.
Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Ass…
-
psnet.ahrq.gov/node/35413/psn-pdf
September 11, 2009 - Lessons learned: basic evidence-based advice for
preventing medication errors in children.
September 11, 2009
Thomas DO. Lessons learned: basic evidence-based advice for preventing medication errors in children.
Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Association.…
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psnet.ahrq.gov/node/46596/psn-pdf
November 01, 2017 - Infection prevention and control in pediatric ambulatory
settings.
November 1, 2017
Rathore MH, Jackson MA, AAP Committee on Infections Diseases. Pediatrics. 2017;140(5):e20172857.
https://psnet.ahrq.gov/issue/infection-prevention-and-control-pediatric-ambulatory-settings
Patient safety in the ambulatory environme…
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psnet.ahrq.gov/node/46293/psn-pdf
January 01, 2021 - Development of the barriers to error disclosure
assessment tool.
September 27, 2017
Welsh D, Zephyr D, Pfeifle AL, et al. Development of the Barriers to Error Disclosure Assessment Tool. J
Patient Saf. 2021;17(5):363-374. doi:10.1097/PTS.0000000000000331.
https://psnet.ahrq.gov/issue/development-barriers-error-dis…
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psnet.ahrq.gov/node/42978/psn-pdf
February 26, 2014 - The Francis Report: One Year On.
February 26, 2014
Thorlby R, Smith J, Williams S, Dayan M. London, UK: Nuffield Trust; February 2014.
https://psnet.ahrq.gov/issue/francis-report-one-year
This publication offers insights from acute care hospital staff in England regarding recommendations from
the Francis rep…
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psnet.ahrq.gov/node/38649/psn-pdf
May 20, 2009 - Managing the adverse event occurring during elective,
ambulatory pediatric surgery.
May 20, 2009
Skarsgard ED. Managing the adverse event occurring during elective, ambulatory pediatric surgery. Semin
Pediatr Surg. 2009;18(2):122-4. doi:10.1053/j.sempedsurg.2009.02.013.
https://psnet.ahrq.gov/issue/managing-advers…
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psnet.ahrq.gov/node/35083/psn-pdf
March 29, 2007 - Patient Safety: Achieving a New Standard for Care.
March 29, 2007
Aspden P ed, Committee for Data Standards for Patient Safety, Institute of Medicine. Washington DC:
National Academies Press; 2004. ISBN 0309090776.
https://psnet.ahrq.gov/issue/patient-safety-achieving-new-standard-care
This report details findings…