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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…
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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.
…
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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…
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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…
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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
…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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
…
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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-…
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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
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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
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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…
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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…
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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…
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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…