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psnet.ahrq.gov/node/73714/psn-pdf
September 15, 2021 - Evaluation of Quality, Safety, and Value in Veterans
Health Administration Facilities, FY 2020.
September 15, 2021
Washington, DC: Veterans Affairs Office of Inspector General; August 26, 2021. Report No. 21-01502-240.
https://psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-f…
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psnet.ahrq.gov/node/43147/psn-pdf
July 19, 2017 - ACOG Committee Opinion #590: preparing for clinical
emergencies in obstetrics and gynecology.
July 19, 2017
Improvement AC of O and GC on PS and Q. Committee opinion no. 590: preparing for clinical emergencies
in obstetrics and gynecology. Obstet Gynecol. 2014;123(3):722-5.
doi:10.1097/01.AOG.0000444442.04111.c6.
…
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psnet.ahrq.gov/node/43426/psn-pdf
July 03, 2016 - Discussing the undiscussable with the powerful: why and
how faculty must learn to counteract organizational
silence.
July 3, 2016
Dankoski ME, Bickel J, Gusic ME. Discussing the undiscussable with the powerful: why and how faculty
must learn to counteract organizational silence. Acad Med. 2014;89(12):1610-3.
doi:…
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www.ahrq.gov/topics/long-term-care.html
Topic: Long-Term Care
AHRQ has toolkits, recommendations, and other resources for long-term care facilities, such as nursing homes and rehabilitation centers, to improve quality, reduce errors, and increase patient safety.
AHRQ Research Findings Support Effort to Reduce Pre…
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psnet.ahrq.gov/node/46032/psn-pdf
May 03, 2017 - Leveraging the Partnership for Patients' initiative to
improve patient safety and quality within the Military
Health System.
May 3, 2017
King HB, Kesling K, Birk C, et al. Leveraging the Partnership for Patients' Initiative to Improve Patient
Safety and Quality Within the Military Health System. Mil Med. 2017;182(…
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psnet.ahrq.gov/node/60274/psn-pdf
April 29, 2020 - Effectiveness of N95 respirators versus surgical masks
against influenza: a systematic review and meta-analysis.
April 29, 2020
Long Y, Hu T, Liu L, et al. Effectiveness of N95 respirators versus surgical masks against influenza: a
systematic review and meta-analysis. J Evid Based Med. 2020. doi:10.1111/jebm.12381.…
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psnet.ahrq.gov/node/61101/psn-pdf
November 04, 2020 - Investigation into Management of Venous
Thromboembolism Risk in Patients Following
Thrombolysis for an Acute Stroke.
November 4, 2020
Farnborough, UK; Healthcare Safety Investigation Branch. October 2020
https://psnet.ahrq.gov/issue/investigation-management-venous-thromboembolism-risk-patients-following-
thrombol…
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psnet.ahrq.gov/node/860732/psn-pdf
April 16, 2024 - Retained Swabs Following Invasive Procedures: Themes
Identified from a Review of NHS Serious Incident Reports.
April 16, 2024
Dorset, UK: Health Services Safety Investigations Body; April 2024.
https://psnet.ahrq.gov/issue/retained-swabs-following-invasive-procedures-themes-identified-review-nhs-
serious-incident
…
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psnet.ahrq.gov/node/60206/psn-pdf
April 08, 2020 - Reducing high-risk medication use through pharmacist-
led interventions in an outpatient setting.
April 8, 2020
Deyo JC, Smith BH, Biola H, et al. Reducing high-risk medication use through pharmacist-led interventions
in an outpatient setting. J Am Pharm Assoc. 2020. doi:10.1016/j.japh.2020.01.013.
https://psnet.a…
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www.ahrq.gov/hai/cusp/toolkit/bckgrnd-qi-team.html
December 01, 2012 - Background Quality Improvement Team Information Form
CUSP Toolkit
Health care provider roles
Who should use this tool? Health care providers.
Please indicate people designated as Quality Improvement Team Members. Your team may not have people who serve in all of these roles.
These in…
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psnet.ahrq.gov/node/50742/psn-pdf
December 18, 2019 - Prioritizing patient safety efforts in office practice settings
December 18, 2019
Kravet SJ, Bhatnagar M, Dwyer M, et al. Prioritizing Patient Safety Efforts in Office Practice Settings. J
Patient Saf. 2019;15(4):e98-e101. doi:10.1097/pts.0000000000000652.
https://psnet.ahrq.gov/issue/prioritizing-patient-safety-ef…
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psnet.ahrq.gov/node/841146/psn-pdf
December 07, 2022 - Exploring the intersection of structural racism and
ageism in healthcare.
December 7, 2022
Farrell TW, Hung WW, Unroe KT, et al. Exploring the intersection of structural racism and ageism in
healthcare. J Am Geriatr Soc. 2022;70(12):3366-3377. doi:10.1111/jgs.18105.
https://psnet.ahrq.gov/issue/exploring-intersect…
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psnet.ahrq.gov/node/850345/psn-pdf
June 14, 2023 - Prevalence and characteristics of diagnostic error in
pediatric critical care: a multicenter study.
June 14, 2023
Cifra CL, Custer JW, Smith CM, et al. Prevalence and characteristics of diagnostic error in pediatric critical
care: a multicenter study. Crit Care Med. 2023;51(11):1492-1501. doi:10.1097/ccm.0000000000…
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psnet.ahrq.gov/node/44534/psn-pdf
April 25, 2016 - Addressing disease-related malnutrition in hospitalized
patients: a call for a national goal.
April 25, 2016
Guenter P, Jensen G, Patel V, et al. Addressing Disease-Related Malnutrition in Hospitalized Patients: A
Call for a National Goal. Jt Comm J Qual Patient Saf. 2015;41(10):469-473.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/38579/psn-pdf
February 18, 2011 - Transitions of Care Consensus Policy Statement
American College of Physicians-Society of General
Internal Medicine-Society of Hospital Medicine-American
Geriatrics Society-American College of Emergency
Physicians-Society of Academic Emergency Medicine.
February 18, 2011
Snow V, Beck D, Budnitz T, et al. Transitio…
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psnet.ahrq.gov/node/46830/psn-pdf
May 30, 2018 - A call to bridge across silos during care transitions.
May 30, 2018
Sheikh F, Gathecha E, Bellantoni M, et al. A Call to Bridge Across Silos during Care Transitions. Jt Comm
J Qual Patient Saf. 2018;44(5):270-278. doi:10.1016/j.jcjq.2017.10.006.
https://psnet.ahrq.gov/issue/call-bridge-across-silos-during-care-tran…
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psnet.ahrq.gov/node/44245/psn-pdf
July 15, 2015 - Patient-initiated second opinions: systematic review of
characteristics and impact on diagnosis, treatment, and
satisfaction.
July 15, 2015
Payne VL, Singh H, Meyer AND, et al. Patient-Initiated Second Opinions: Systematic Review of
Characteristics and Impact on Diagnosis, Treatment, and Satisfaction. Mayo Clinic …
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psnet.ahrq.gov/node/44742/psn-pdf
January 06, 2016 - A piece of my mind. From shame to guilt to love.
January 6, 2016
Pronovost P, Bienvenu J. A piece of my mind. From shame to guilt to love. JAMA. 2015;314(23):2507-
2508. doi:10.1001/jama.2015.11521.
https://psnet.ahrq.gov/issue/piece-my-mind-shame-guilt-love
While numerous studies have examined the psychological i…
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psnet.ahrq.gov/node/42662/psn-pdf
October 16, 2013 - Informal learning from error in hospitals: what do we
learn, how do we learn and how can informal learning be
enhanced? A narrative review.
October 16, 2013
de Feijter JM, de Grave WS, Koopmans RP, et al. Informal learning from error in hospitals: what do we
learn, how do we learn and how can informal learning be …
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psnet.ahrq.gov/node/837805/psn-pdf
August 10, 2022 - Adverse events in infants less than 6 months of age after
ambulatory surgery and diagnostic imaging requiring
anesthesia.
August 10, 2022
Uffman JC, Kim SS, Quan LN, et al. Adverse events in infants less than 6 months of age after ambulatory
surgery and diagnostic imaging requiring anesthesia. Pediatr Qual Saf. 20…