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psnet.ahrq.gov/node/45189/psn-pdf
February 19, 2019 - SaferCare Texas
February 19, 2019
UNT Health Science Center; University of North Texas Health Science Center; UNTHSC.
https://psnet.ahrq.gov/issue/safercare-texas
Regional programs for patient safety seek to provide communities with resources targeted to distinct needs
and populations while addressing key areas of…
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psnet.ahrq.gov/node/36124/psn-pdf
June 15, 2011 - System failure versus personal accountability--the case
for clean hands.
June 15, 2011
Goldmann DA. System failure versus personal accountability--the case for clean hands. N Engl J Med.
2006;355(2):121-3.
https://psnet.ahrq.gov/issue/system-failure-versus-personal-accountability-case-clean-hands
The author argue…
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psnet.ahrq.gov/node/34606/psn-pdf
July 06, 2011 - Operating at the sharp end: the complexity of human
error.
July 6, 2011
Cook RI, Woods DD. Chapter In: Bogner MS, ed. Human Error in Medicine. Hillsdale NJ: Lawrence
Erlbaum Associates, Inc; 2004.
https://psnet.ahrq.gov/issue/operating-sharp-end-complexity-human-error
The authors provide an introduction to system…
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psnet.ahrq.gov/node/37251/psn-pdf
February 28, 2018 - Drug labeling and packaging — looking beyond what
meets the eye.
February 28, 2018
PA-PSRS Patient Safety Advisory.
https://psnet.ahrq.gov/issue/drug-labeling-and-packaging-looking-beyond-what-meets-eye
Drawing from data submitted to the Patient Safety Authority reporting system, this article documents factors
in…
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psnet.ahrq.gov/node/45078/psn-pdf
June 28, 2019 - Common Formats for Event Reporting.
June 28, 2019
National Quality Forum.
https://psnet.ahrq.gov/issue/comments-common-formats-event-reporting-hospital-version-03-beta
Patient safety organizations collect data across various systems and states. This site supports review and
comment of versions of common formats de…
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psnet.ahrq.gov/node/38647/psn-pdf
May 20, 2009 - A next act for patient safety.
May 20, 2009
Viola AF, Kallem C, Bronnert J. A next act for patient safety. J AHIMA. 2009;80(4):30-5; quiz 37-8.
https://psnet.ahrq.gov/issue/next-act-patient-safety
This article provides an overview of the Patient Safety and Quality Improvement Act and addresses the
potential roles …
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psnet.ahrq.gov/node/34925/psn-pdf
February 27, 2009 - Medication errors and professional practice of registered
nurses.
February 27, 2009
Deans C. Medication errors and professional practice of registered nurses. Collegian. 2005;12(1):29-33.
https://psnet.ahrq.gov/issue/medication-errors-and-professional-practice-registered-nurses
This Australian study identified and…
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psnet.ahrq.gov/node/40421/psn-pdf
January 01, 2020 - Safe Surgery 2020.
April 27, 2011
GE Foundation. info@safesurgery2020.org.
https://psnet.ahrq.gov/issue/safe-surgery-2015
This Web site provides programmatic resources building on work to implement the World Health
Organization surgical safety checklist to improve surgical safety worldwide. Its efforts center…
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psnet.ahrq.gov/node/40023/psn-pdf
November 24, 2010 - Health literacy and communication quality in health care
organizations.
November 24, 2010
Wynia M, Osborn CY. Health literacy and communication quality in health care organizations. J Health
Commun. 2010;15 Suppl 2:102-15. doi:10.1080/10810730.2010.499981.
https://psnet.ahrq.gov/issue/health-literacy-and-communica…
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psnet.ahrq.gov/training-catalog/ismp-education-solutions
September 14, 2025 - ISMP Education Solutions
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Organization:
Organization
ECRI Institute
Event Description: As a global leader in medication s…
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psnet.ahrq.gov/node/38375/psn-pdf
December 01, 2019 - ISMP QuarterWatch Reports.
April 17, 2019
Horsham, PA: Institute for Safe Medication Practices.
https://psnet.ahrq.gov/issue/ismp-quarterwatch-reports
This website provides quarterly reports that identify and analyze new risks related to medications and
adverse drug events submitted to the Food and Drug Administra…
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psnet.ahrq.gov/node/35922/psn-pdf
July 26, 2010 - Nursing 2006 Patient-safety survey report.
July 26, 2010
Manno M, Hogan P, Heberlein V, et al. Nursing 2006. Patient-safety survey report. Nursing (Brux).
2006;36(5):54-64.
https://psnet.ahrq.gov/issue/nursing-2006-patient-safety-survey-report
The investigators analyzed the results of a 2005 survey of approximatel…
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psnet.ahrq.gov/node/40317/psn-pdf
November 21, 2016 - Achieving an Exceptional Patient and Family Experience
of Inpatient Hospital Care.
November 21, 2016
Balik B, Conway J, Zipperer L, Watson J. Cambridge, MA: Institute for Healthcare Improvement; 2011.
https://psnet.ahrq.gov/issue/achieving-exceptional-patient-and-family-experience-inpatient-hospital-care
This whit…
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psnet.ahrq.gov/node/33950/psn-pdf
February 05, 2018 - Quick Tips--When Planning for Surgery.
February 5, 2018
Rockville, MD: Agency for Health Care Policy and Research; 2005. AHRQ Pub. No. 01-0040d.
https://psnet.ahrq.gov/issue/quick-tips-when-planning-surgery-0
This AHRQ brochure provides practical advice for patients facing non-emergent surgery, to help them be
gen…
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psnet.ahrq.gov/node/33970/psn-pdf
March 07, 2005 - Failure in Safety-Critical Systems: A Handbook of
Accident and Incident Reporting.
March 7, 2005
Johnson CW. Glasgow, Scotland: University of Glasgow Press; 2003. ISBN 0852617844.
https://psnet.ahrq.gov/issue/failure-safety-critical-systems-handbook-accident-and-incident-reporting
The author provides engineers and…
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psnet.ahrq.gov/node/44313/psn-pdf
November 28, 2023 - Resilient Health Care Society.
November 28, 2023
Sweden.
https://psnet.ahrq.gov/issue/resilient-health-care-society
Resilience engineering provides a structure to enable teams and organizations to respond to emergent
problems. This initiative supports networking and research related to this approach to ensure the …
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psnet.ahrq.gov/node/42808/psn-pdf
December 18, 2013 - Patient safety education: what was, what is, and what will
be?
December 18, 2013
Klamen D, Sanserino K, Skolnik PJ. Patient Safety Education: What Was, What Is, and What Will Be?
Teach Learn Med. 2013;25(sup1). doi:10.1080/10401334.2013.842906.
https://psnet.ahrq.gov/issue/patient-safety-education-what-was-what-an…
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psnet.ahrq.gov/node/43360/psn-pdf
September 29, 2017 - Antimicrobial Stewardship Toolkit.
September 29, 2017
Chicago, IL: American Hospital Association Physician Leadership Forum; July 2014.
https://psnet.ahrq.gov/issue/antimicrobial-stewardship-toolkit
Antimicrobial stewardship has been promoted as an element of patient safety. This toolkit provides
resources for hos…
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psnet.ahrq.gov/node/47675/psn-pdf
November 28, 2023 - SOPS Surveys.
November 28, 2023
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/sops-surveys
Surveys are established mechanisms for organizational assessment of safety culture. This collection of
webinars provides an overview of the AHRQ Surveys on Patient Safety Culture™ (SOPS®) and a ran…
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psnet.ahrq.gov/node/60035/psn-pdf
September 22, 2023 - SOPS Medical Office Database.
March 11, 2020
Agency for Healthcare Research and Quality (AHRQ). March 2020.
https://psnet.ahrq.gov/issue/sops-medical-office-database
This website provides a report and data repository representing medical offices that administered the
AHRQ Surveys on Patient Safety Culture™ (SOPS®)…