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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…
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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…
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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 …
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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 …
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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…
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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…
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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…
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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…
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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…
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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
…
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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…
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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/…
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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…
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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…
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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…
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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.
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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…
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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…
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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
…
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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.
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