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psnet.ahrq.gov/node/42955/psn-pdf
May 11, 2016 - National Patient Safety Alerting System.
May 11, 2016
National Health Service England
https://psnet.ahrq.gov/issue/national-patient-safety-alerting-system
In response to the Francis report, this three-stage reporting system was launched to help National Health
Service organizations learn from incidents and incorpo…
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psnet.ahrq.gov/node/48072/psn-pdf
June 19, 2019 - Independent double checks: worth the effort if used
judiciously and properly.
June 19, 2019
ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24:1-7.
https://psnet.ahrq.gov/issue/independent-double-checks-worth-effort-if-used-judiciously-and-properly
Independent double checks can reduce risk of human …
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psnet.ahrq.gov/node/74143/psn-pdf
December 01, 2021 - Confronting Racism in Health Care: Moving from
Proclamations to New Practices.
December 1, 2021
Hostetter M, Klein S. New York, NY: Commonwealth Fund; October 18, 2021
https://psnet.ahrq.gov/issue/confronting-racism-health-care-moving-proclamations-new-practices
Structural racism affects the safety and equit…
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psnet.ahrq.gov/node/44495/psn-pdf
September 30, 2015 - Impact of laws aimed at healthcare-associated infection
reduction: a qualitative study.
September 30, 2015
Stone PW, Pogorzelska-Maziarz M, Reagan J, et al. Impact of laws aimed at healthcare-associated
infection reduction: a qualitative study. BMJ Qual Saf. 2015;24(10):637-44. doi:10.1136/bmjqs-2014-
003921.
htt…
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psnet.ahrq.gov/node/42925/psn-pdf
February 05, 2014 - Understanding the Role of Facility Design in the
Acquisition and Prevention of Healthcare-Associated
Infections.
February 5, 2014
Hamilton DK, Stichler JF, eds. HERD. 2013;7(suppl):1-154.
https://psnet.ahrq.gov/issue/understanding-role-facility-design-acquisition-and-prevention-healthcare-
associated
Articles in…
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psnet.ahrq.gov/node/836999/psn-pdf
April 27, 2022 - Toolkit for Preventing CLABSI and CAUTI in ICUs.
April 27, 2022
Rockville, MD: Agency for Healthcare Research and Quality; April 2022.
https://psnet.ahrq.gov/issue/toolkit-preventing-clabsi-and-cauti-icus
Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this
cu…
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psnet.ahrq.gov/node/41296/psn-pdf
April 11, 2012 - I-PASS, a mnemonic to standardize verbal handoffs.
April 11, 2012
Starmer AJ, Spector ND, Srivastava R, et al. I-pass, a mnemonic to standardize verbal handoffs.
Pediatrics. 2012;129(2):201-4. doi:10.1542/peds.2011-2966.
https://psnet.ahrq.gov/issue/i-pass-mnemonic-standardize-verbal-handoffs
Poor communication at…
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psnet.ahrq.gov/node/39993/psn-pdf
July 03, 2014 - The influence of organizational context on quality
improvement and patient safety efforts in infection
prevention: a multi-center qualitative study.
July 3, 2014
Krein SL, Damschroder LJ, Kowalski CP, et al. The influence of organizational context on quality
improvement and patient safety efforts in infection prev…
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psnet.ahrq.gov/node/47781/psn-pdf
February 27, 2019 - Medicine Safety: Take Care.
February 27, 2019
Lim R, Semple S, Ellett LK, Roughead L. Canberra, Australia: Pharmaceutical Society of Australia; 2019.
https://psnet.ahrq.gov/issue/medicine-safety-take-care
Analyzing the evidence on medication errors in Australia, this report estimates the incidence of acute care
ad…
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psnet.ahrq.gov/node/47485/psn-pdf
January 09, 2019 - System-related and cognitive errors in laboratory
medicine.
January 9, 2019
Plebani M. System-related and cognitive errors in laboratory medicine. Diagnosis (Berl). 2018;5(4):191-
196. doi:10.1515/dx-2018-0085.
https://psnet.ahrq.gov/issue/system-related-and-cognitive-errors-laboratory-medicine
Problems managing …
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psnet.ahrq.gov/node/44488/psn-pdf
September 16, 2015 - Environmental Cleaning for the Prevention of Healthcare-
Associated Infections (HAIs).
September 16, 2015
Leas BF, Sullivan N, Han JH, Pegues DA, Kaczmarek JL, Umscheid CA. Rockville, MD: Agency for
Healthcare Research and Quality; August 2015. Technical Brief No. 22. AHRQ Publication No. 15-
EHC020-EF.
https://p…
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psnet.ahrq.gov/node/35470/psn-pdf
July 10, 2008 - Prevention of fall-related injuries in long-term care: a
randomized controlled trial of staff education.
July 10, 2008
Ray WA, Taylor JA, Brown AK, et al. Prevention of fall-related injuries in long-term care: a randomized
controlled trial of staff education. Arch Intern Med. 2005;165(19):2293-8.
https://psnet.ahr…
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psnet.ahrq.gov/node/837979/psn-pdf
August 31, 2022 - Maternal Health Research Centers of Excellence (U54
Clinical Trial Optional).
August 31, 2022
National Institutes of Health. August 11, 2022. RFA-HD-23-035.
https://psnet.ahrq.gov/issue/maternal-health-research-centers-excellence-u54-clinical-trial-optional
Maternity care is increasingly being recognized as …
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psnet.ahrq.gov/node/863223/psn-pdf
February 28, 2024 - Prioritizing Patient Safety Through Quality Measurement.
February 28, 2024
Centers for Medicare & Medicaid Services, March 6 and 21, 2024.
https://psnet.ahrq.gov/issue/prioritizing-patient-safety-through-quality-measurement
Quality measurement intersects with patient safety and care improvement efforts to…
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psnet.ahrq.gov/node/44846/psn-pdf
August 31, 2016 - Making health care safer: protect patients from antibiotic
resistance.
August 31, 2016
CDC; Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/making-health-care-safer-protect-patients-antibiotic-resistance
Health care–associated infections (HAI) are a worldwide patient safety problem. This a…
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psnet.ahrq.gov/node/50825/psn-pdf
January 22, 2020 - Investigation into Detection of Retained Vaginal Swabs
and Tampons Following Childbirth.
January 22, 2020
Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.
https://psnet.ahrq.gov/issue/investigation-detection-retained-vaginal-swabs-and-tampons-following-
childbirth
Maternal care during a…
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psnet.ahrq.gov/node/50781/psn-pdf
January 08, 2020 - Harnessing the power of medical malpractice data to
improve patient care.
January 8, 2020
Siegal D, Swift J, Forget J, et al. Harnessing the power of medical malpractice data to improve patient care.
J Healthc Risk Manag. 2020;39(3):28-36. doi:10.1002/jhrm.21393.
https://psnet.ahrq.gov/issue/harnessing-power-medic…
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psnet.ahrq.gov/node/848044/psn-pdf
April 26, 2023 - Effect of a hospital command centre on patient safety: an
interrupted time series study.
April 26, 2023
Mebrahtu TF, McInerney CD, Benn J, et al. BMJ Health Care Inform. 2023;30(1):e100653.
https://psnet.ahrq.gov/issue/effect-hospital-command-centre-patient-safety-interrupted-time-series-study
Command centers…
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psnet.ahrq.gov/node/836972/psn-pdf
April 20, 2022 - Diagnostic Centers of Excellence: Partnerships to
Improve Diagnostic Safety and Quality (R18).
April 20, 2022
Rockville, MD: Agency for Healthcare Research and Quality; April 7, 2022. RFA-HS-22-008.
https://psnet.ahrq.gov/issue/diagnostic-centers-excellence-partnerships-improve-diagnostic-safety-and-
quality-r18
…
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psnet.ahrq.gov/node/846455/psn-pdf
March 22, 2023 - Diagnostic Centers of Excellence (X01 Clinical Trial Not
Allowed).
March 22, 2023
PAR-23-120. Bethesda, MD: National Institutes of Health; March 7, 2023
https://psnet.ahrq.gov/issue/diagnostic-centers-excellence-x01-clinical-trial-not-allowed
Approaching diagnosis as a team activity is seen as a key approach to di…