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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43233/psn-pdf
    June 17, 2014 - Quality and safety education for nurses: a nursing leadership skills exercise. June 17, 2014 Harrison EM. Quality and safety education for nurses: a nursing leadership skills exercise. J Nurs Educ. 2014;53(6):356-361. doi:10.3928/01484834-20140512-01. https://psnet.ahrq.gov/issue/quality-and-safety-education-nurse…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37788/psn-pdf
    May 28, 2008 - Durable improvements in efficiency, safety, and satisfaction in the operating room. May 28, 2008 Heslin MJ, Doster BE, Daily SL, et al. Durable improvements in efficiency, safety, and satisfaction in the operating room. J Am Coll Surg. 2008;206(5):1083-9; discussion 1089-90. doi:10.1016/j.jamcollsurg.2008.02.006. …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40951/psn-pdf
    December 21, 2014 - Quality and safety in medical care: what does the future hold? December 21, 2014 Liang BA, Mackey T. Quality and safety in medical care: what does the future hold? Arch Pathol Lab Med. 2011;135(11):1425-31. doi:10.5858/arpa.2011-0154-OA. https://psnet.ahrq.gov/issue/quality-and-safety-medical-care-what-does-future…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41075/psn-pdf
    January 18, 2012 - Wide heart monitor use tied to missed alarms. January 18, 2012 Funk M, Winkler CG, May JL, et al. Unnecessary arrhythmia monitoring and underutilization of ischemia and QT interval monitoring in current clinical practice: baseline results of the Practical Use of the Latest Standards for Electrocardiography trial. J…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50667/psn-pdf
    November 13, 2019 - Proactive prevention of maternal death from maternal hemorrhage. November 13, 2019 Quick Safety. October 29, 2019;(51):1-3. https://psnet.ahrq.gov/issue/proactive-prevention-maternal-death-maternal-hemorrhage The reduction of postpartum hemorrhage and the overall improvement of maternal safety is a patient safety …
  6. digital.ahrq.gov/ahrq-funded-projects/success-stories/text-messaging-managing-chronic-disease
    January 01, 2023 - Text Messaging for Managing Chronic Disease Your browser does not support inline frames. Please go to http://youtu.be/bpP8xawfoi4 to view the video. Principal Investigator: Jennifer Uhrig (Contract No. HHSA290200600001I #7) [5 min., 10 sec.] This project showed that text messaging can effec…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38822/psn-pdf
    July 29, 2009 - The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited. July 29, 2009 Stahel PF, Mehler PS, Clarke TJ, et al. The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited. Patient Saf Surg. 2009;3(1):14. doi:10.1186/1754-9493-3-14. https://psnet.ahrq.gov/issue/5th-annivers…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43216/psn-pdf
    June 25, 2014 - Banning the handshake from the health care setting. June 25, 2014 Sklansky M, Nadkarni N, Ramirez-Avila L. Banning the handshake from the health care setting. JAMA. 2014;311(24):2477-8. https://psnet.ahrq.gov/issue/banning-handshake-health-care-setting Hand hygiene is an important practice that prevents transmissi…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72863/psn-pdf
    March 17, 2021 - 7 ways to prevent medical errors. March 17, 2021 Caceres V. US News World Report. March 1, 2021. https://psnet.ahrq.gov/issue/7-ways-prevent-medical-errors Patients and families have an important role in reducing potential for error and harm. This article highlights a set of tactics for patients to enhan…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36810/psn-pdf
    November 19, 2014 - A Systems Approach to Quality Improvement in Long- Term Care: Safe Medication Practices Workbook. November 19, 2014 Massachusetts Coalition for the Prevention of Medical Errors, MassPRO, Massachusetts Extended Care Foundation. Boston, MA: Commonwealth of Massachusetts; 2008. https://psnet.ahrq.gov/issue/systems-ap…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73520/psn-pdf
    July 21, 2021 - Geriatric medication reconciliation in the home setting. July 21, 2021 Taylor K. American Nurse J. 2021;16(7):14-17. https://psnet.ahrq.gov/issue/geriatric-medication-reconciliation-home-setting Medication reconciliation reduces the potential for problems in complicated medication regimens. This article share…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39344/psn-pdf
    March 03, 2010 - Mistake-proofing healthcare: why stopping processes may be a good start. March 3, 2010 Grout JR, Toussaint JS. Mistake-proofing healthcare: Why stopping processes may be a good start. Bus Horiz. 2009;53(2):149-156. doi:10.1016/j.bushor.2009.10.007. https://psnet.ahrq.gov/issue/mistake-proofing-healthcare-why-stopp…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47348/psn-pdf
    September 05, 2018 - Hospital-Acquired Condition Reduction Program (HACRP). September 5, 2018 QualityNet. Centers for Medicare and Medicaid Services. https://psnet.ahrq.gov/issue/hospital-acquired-condition-hac-reduction-program Eliminating hospital-acquired harm requires policy, organizational, and individual approaches to motivate …
  14. www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-decline.pdf
    June 02, 2025 - Declines in Hospital Acquired Conditions Declines in Hospital- Acquired Conditions National efforts to reduce hospital-acquired conditions such as adverse drug events and injuries from falls helped prevent 8,000 deaths and saved $2.9 billion between 2014 and 2016. Adverse Drug Events CAUTI* *CAUTI - Catheter-…
  15. digital.ahrq.gov/sites/default/files/docs/citation/r21hs024587-schnipper-final-report-2019.pdf
    January 01, 2019 - They may find that the improvements in medication adherence and disease control, possibly leading to reduced … integrated delivery systems, where investments in time and resources may be practical in exchange for reduced
  16. Wafinalreport042309 (pdf file)

    hcup-us.ahrq.gov/datainnovations/clinicaldata/WAFinalReport042309.pdf
    April 23, 2009 - a mandate for data collection from hospitals, vendors will change their data systems for free or reduced … indicated that they needed a mandate for their vendors to change their data systems for free or reduced
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850675/psn-pdf
    June 14, 2023 - Patient and Family Roles in Safety June 14, 2023 Johnson B, Lee M, Mossburg S. Patient and Family Roles in Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/patient-and-family-roles-safety Moving From Engagement to Partnership Involving patients and families in healthcare decisions about patient c…
  18. psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
    October 26, 2022 - Diagnosing a Missed Diagnosis Citation Text: Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7…
  19. www.ahrq.gov/sites/default/files/2025-04/castro-report.pdf
    January 01, 2025 - Final Progress Report: Diagnostic Error in Medicine Conference 2020-2022 Title Page – Final Progress Report Title: Diagnostic Error in Medicine Conference 2020-2022 Principal Investigator: Gerry Castro, PhD, MPH Team Members: 2022 Conference Chairs, Co-chairs and Planning Commitee members Andrew Olson…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846563/psn-pdf
    March 21, 2023 - Impact of System Failures on Healthcare Workers March 21, 2023 Zangaro G, Van CM, Mossburg S. Impact of System Failures on Healthcare Workers . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers Introduction The March 2022 conviction of RaDonda Vaught, a former nu…