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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41440/psn-pdf
    August 17, 2016 - The Toolkit for Using the AHRQ Quality Indicators: How To Improve Hospital Quality and Safety. August 17, 2016 Rockville, MD: Agency for Healthcare Research and Quality; July 2016. https://psnet.ahrq.gov/issue/toolkit-using-ahrq-quality-indicators-how-improve-hospital-quality-and-safety This toolkit provides resou…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47260/psn-pdf
    August 08, 2018 - Building the Case for Health Literacy: Proceedings of a Workshop. August 8, 2018 National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press; 2018. ISBN: 9780309474290. https://psnet.ahrq.gov/issue/building-case-health-literacy-proceedings-workshop Health literacy affects p…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72585/psn-pdf
    December 16, 2020 - Think health care workers are tested often for the Coronavirus? Think again. December 16, 2020 Wamsley L. National Public Radio and WBUR. December 7, 2020. https://psnet.ahrq.gov/issue/think-health-care-workers-are-tested-often-coronavirus-think-again Testing for COVID-19 is a core public safety strategy for …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844551/psn-pdf
    February 15, 2023 - Emotional safety is patient safety. February 15, 2023 Lyndon A, Davis D-A, Sharma AE, et al. Emotional safety is patient safety. BMJ Qual Saf. 2023;32(7):369- 372. doi:10.1136/bmjqs-2022-015573. https://psnet.ahrq.gov/issue/emotional-safety-patient-safety Patient perspectives can provide unique insights into care …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38970/psn-pdf
    July 05, 2013 - Joint Commission Center for Transforming Healthcare. July 5, 2013 Joint Commission. https://psnet.ahrq.gov/issue/joint-commission-center-transforming-healthcare The Joint Commission has traditionally focused on accreditation of health care organizations and, through its Joint Commission Resources arm, on quality i…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73245/psn-pdf
    May 12, 2021 - Just culture: the foundation of staff safety in the perioperative environment. May 12, 2021 Fencl JL, Willoughby C, Jackson K. Just culture: the foundation of staff safety in the perioperative environment. AORN J. 2021;113(4):329-336. doi:10.1002/aorn.13352. https://psnet.ahrq.gov/issue/just-culture-foundation-sta…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45111/psn-pdf
    May 11, 2016 - Educational opportunities with postevent debriefing. May 11, 2016 Mullan PC, Kessler DO, Cheng A. Educational opportunities with postevent debriefing. JAMA. 2014;312(22):2333-4. doi:10.1001/jama.2014.15741. https://psnet.ahrq.gov/issue/educational-opportunities-postevent-debriefing Real-time or near real-time lear…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837847/psn-pdf
    August 17, 2022 - Defining and studying errors in surgical care: a systematic review. August 17, 2022 Marsh KM, Turrentine FE, Knight K, et al. Defining and studying errors in surgical care: a systematic review. Ann Surg. 2022;275(6):1067-1073. doi:10.1097/sla.0000000000005351. https://psnet.ahrq.gov/issue/defining-and-studying-err…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73377/psn-pdf
    June 09, 2021 - An examination of factors that predict the perioperative culture of safety. June 9, 2021 Wright MI, Polivka B, Abusalem S. An examination of factors that predict the perioperative culture of safety. AORN J. 2021;113(5):465-475. doi:10.1002/aorn.13373. https://psnet.ahrq.gov/issue/examination-factors-predict-periop…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46512/psn-pdf
    August 17, 2018 - The problem with using patient complaints for improvement. August 17, 2018 de Vos MS, Hamming JF, van de Mheen PJM-. The problem with using patient complaints for improvement. BMJ Qual Saf. 2018;27(9):758-762. doi:10.1136/bmjqs-2017-007463. https://psnet.ahrq.gov/issue/problem-using-patient-complaints-improvement …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867449/psn-pdf
    March 13, 2025 - Medication Related Harm. March 13, 2025 Medication Related Harm. Health Services Safety Investigations Body. 2024-2025 https://psnet.ahrq.gov/issue/medication-related-harm Omitted or delayed medication therapy can contribute to patient discomfort, stress, and harm. This series of reports, to be developed over 2024…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60696/psn-pdf
    July 15, 2020 - Culture as a Cure: Assessments of Patient Safety Culture in OECD Countries. July 15, 2020 de Bienassisi K, Kristensenii S, Burtscheri M, et al for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 119. https://psnet.ahrq.gov/…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34747/psn-pdf
    August 04, 2009 - The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. August 4, 2009 Langley GJ, Moen R, Nolan KM, et al. Hoboken, NJ: Jossey-Bass; 2009. ISBN: 9780470430880. https://psnet.ahrq.gov/issue/improvement-guide-practical-approach-enhancing-organizational-performance- 2nd-ed Effec…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34663/psn-pdf
    December 23, 2008 - Improving the quality of health care: who will lead? December 23, 2008 Becher EC, Chassin MR. Improving the quality of health care: who will lead? Health Aff (Millwood). 2001;20(5):164-79. https://psnet.ahrq.gov/issue/improving-quality-health-care-who-will-lead In this review, Becher and Chassin discuss the persis…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49422/psn-pdf
    November 01, 2003 - 40 of K November 1, 2003 Lesar TS. 40 of K. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/40-k The Case An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…
  16. psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access
    September 01, 2005 - Benefits vs. Risks of Intraosseous Vascular Access Citation Text: Fowler RL, Lippmann MJ. Benefits vs. Risks of Intraosseous Vascular Access. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Go…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49734/psn-pdf
    May 01, 2015 - Departure From Central Line Ritual May 1, 2015 Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/departure-central-line-ritual The Case A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency, and alco…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49713/psn-pdf
    June 01, 2014 - CVC Removal: A Procedure Like Any Other June 1, 2014 Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other The Case A 27-year-old man with a history of Behçet disease and recurrent liver abscesses was admitted to the hospital for a p…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73999/psn-pdf
    October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room October 27, 2021 Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room …
  20. psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
    April 28, 2021 - Procedural Mishap: Learning Curve? Citation Text: Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

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