-
psnet.ahrq.gov/node/849136/psn-pdf
May 17, 2023 - Using morbidity and mortality conferences to drive
quality improvement and reduce errors.
May 17, 2023
Lai B, Horn J, Wilkinson J, et al. Fam Pract Manag. 2023;30(2):13-17.
https://psnet.ahrq.gov/issue/using-morbidity-and-mortality-conferences-drive-quality-improvement-and-
reduce-errors
Morbidity and mortality (…
-
psnet.ahrq.gov/node/47431/psn-pdf
September 26, 2018 - Partnering with pediatric patients and families in high
reliability to identify and reduce preventable safety
events.
September 26, 2018
Kirby J, Cannon C, Darrah L, et al. Patient Exp J. 2018;5:76-90.
https://psnet.ahrq.gov/issue/partnering-pediatric-patients-and-families-high-reliability-identify-and-reduce-
pr…
-
psnet.ahrq.gov/node/45867/psn-pdf
April 12, 2017 - The Economics of Patient Safety: Strengthening a Value-
based Approach to Reducing Patient Harm at National
Level.
April 12, 2017
Slawomirski L, Auraaen A, Klazinga N. Organisation for Economic Co-operation and Development: Paris,
France; 2017.
https://psnet.ahrq.gov/issue/economics-patient-safety-strengthening-v…
-
psnet.ahrq.gov/node/34657/psn-pdf
June 14, 2011 - Multidisciplinary approaches to reducing error and risk in
a patient care setting.
June 14, 2011
Connor M, Ponte PR, Conway JB. Multidisciplinary approaches to reducing error and risk in a patient care
setting. Crit Care Nurs Clin North Am. 2002;14(4):359-67, viii.
https://psnet.ahrq.gov/issue/multidisciplinary-ap…
-
psnet.ahrq.gov/node/34784/psn-pdf
June 24, 2015 - The potential for improved teamwork to reduce medical
errors in the emergency department.
June 24, 2015
Risser DT, Rice MM, Salisbury ML, et al. The potential for improved teamwork to reduce medical errors in
the emergency department. Ann Emerg Med. 2005;34(3):373-383. doi:10.1016/s0196-0644(99)70134-4.
https://ps…
-
psnet.ahrq.gov/node/42745/psn-pdf
October 31, 2014 - Do variations in hospital mortality patterns after weekend
admission reflect reduced quality of care or different
patient cohorts? A population-based study.
October 31, 2014
Concha OP, Gallego B, Hillman K, et al. Do variations in hospital mortality patterns after weekend
admission reflect reduced quality of care …
-
psnet.ahrq.gov/node/47455/psn-pdf
October 31, 2018 - Assessment of opioid prescribing practices before and
after implementation of a health system intervention to
reduce opioid overprescribing.
October 31, 2018
Meisenberg BR, Grover J, Campbell C, et al. Assessment of Opioid Prescribing Practices Before and After
Implementation of a Health System Intervention to Red…
-
psnet.ahrq.gov/node/47651/psn-pdf
December 12, 2018 - Are national efforts to reduce drug name confusion
paying off?
December 12, 2018
ISMP Medication Safety Alert! Acute Care Edition. November 29, 2018;23:1-6.
https://psnet.ahrq.gov/issue/are-national-efforts-reduce-drug-name-confusion-paying
Look-alike and sound-alike medications present a recurring threat to patie…
-
psnet.ahrq.gov/node/61077/psn-pdf
October 28, 2020 - Investigation into the Role of Clinical Pharmacy Services
in Helping to Identify and Reduce High-risk Prescribing
Errors in Hospital.
October 28, 2020
Farnborough, UK: Healthcare Safety Investigation Branch; September 24, 2020.
https://psnet.ahrq.gov/issue/investigation-role-clinical-pharmacy-servi…
-
psnet.ahrq.gov/node/47989/psn-pdf
August 14, 2019 - Ambulatory safety nets to reduce missed and delayed
diagnoses of cancer.
August 14, 2019
Emani S, Sequist TD, Lacson R, et al. Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses
of Cancer. Jt Comm J Qual Patient Saf. 2019;45(8):552-557. doi:10.1016/j.jcjq.2019.05.010.
https://psnet.ahrq.gov/issue/ambula…
-
psnet.ahrq.gov/node/47987/psn-pdf
May 08, 2019 - Association between night-time surgery and occurrence
of intraoperative adverse events and postoperative
pulmonary complications.
May 8, 2019
Cortegiani A, Gregoretti C, Neto AS, et al; LAS VEGAS Investigators, PROVE Network, Clinical Trial
Network of the European Society of Anaesthesiology. Br J Anaesth. 2019;122…
-
psnet.ahrq.gov/node/45098/psn-pdf
May 04, 2016 - Reducing Risk and Promoting Patient Safety for NIH
Intramural Clinical Research—Final Report.
May 4, 2016
The Clinical Center Working Group Report to the Advisory Committee to the Director, National Institutes of
Health. Bethesda, MD; National Institutes of Health; April 2016.
https://psnet.ahrq.gov/issue/reducing…
-
psnet.ahrq.gov/node/867702/psn-pdf
September 01, 2021 - Toolkit To Reduce CAUTI and Other HAIs in Long-Term
Care Facilities.
September 1, 2021
Agency for Healthcare Research and Quality. Toolkit To Reduce CAUTI and Other HAIs in Long-Term
Care Facilities. September 2021.
https://psnet.ahrq.gov/issue/toolkit-reduce-cauti-and-other-hais-long-term-care-facilities
Cathete…
-
psnet.ahrq.gov/node/866846/psn-pdf
September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement
September 24, 2024
Stockmeier CA, Thomas E, Mossburg S, et al. Zero Harm: Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/zero…
-
psnet.ahrq.gov/node/50852/psn-pdf
January 29, 2020 - Failure mode and effects analysis to reduce risk of
heparin use.
January 29, 2020
Pino FA, Weidemann DK, Schroeder LL, et al. Failure mode and effects analysis to reduce risk of heparin
use. Am J Health Syst Pharm. 2019;76(23):1972-1979. doi:10.1093/ajhp/zxz229.
https://psnet.ahrq.gov/issue/failure-mode-and-effect…
-
psnet.ahrq.gov/node/36348/psn-pdf
March 09, 2009 - Reducing medical error in the Military Health System: how
can team training help?
March 9, 2009
Alonso A, Baker DP, Holtzman A, et al. Reducing medical error in the Military Health System: How can
team training help? Human Resource Management Review. 2006;16(3). doi:10.1016/j.hrmr.2006.05.006.
https://psnet.ahrq.g…
-
psnet.ahrq.gov/node/38569/psn-pdf
May 20, 2009 - Reducing health care hazards: lessons from the
Commercial Aviation Safety Team.
May 20, 2009
Pronovost P, Goeschel CA, Olsen KL, et al. Reducing health care hazards: lessons from the commercial
aviation safety team. Health Aff (Millwood). 2009;28(3):w479-89. doi:10.1377/hlthaff.28.3.w479.
https://psnet.ahrq.gov/is…
-
psnet.ahrq.gov/node/866317/psn-pdf
July 17, 2024 - BONE break: a hot debrief tool to reduce second victim
syndrome for nurses.
July 17, 2024
Hess A, Flicek T, Watral AT, et al. BONE break: a hot debrief tool to reduce second victim syndrome for
nurses. Jt Comm J Qual Patient Saf. 2024;50(9):673-677. doi:10.1016/j.jcjq.2024.05.005.
https://psnet.ahrq.gov/issue/bone…
-
psnet.ahrq.gov/node/73464/psn-pdf
July 07, 2021 - Errors in breast imaging: how to reduce errors and
promote a safety environment.
July 7, 2021
Sivarajah R, Dinh ML, Chetlen A. Errors in breast imaging: how to reduce errors and promote a safety
environment. J Breast Imaging. 2021;3(2):221-230. doi:10.1093/jbi/wbaa118.
https://psnet.ahrq.gov/issue/errors-breast-im…
-
psnet.ahrq.gov/node/47216/psn-pdf
July 11, 2018 - Progress Made Towards Improving Opioid Safety, But
Further Efforts to Assess Progress and Reduce Risk Are
Needed.
July 11, 2018
Washington, DC: United States Government Accountability Office; May 2018. Publication GAO-18-380.
https://psnet.ahrq.gov/issue/progress-made-towards-improving-opioid-safety-further-effort…