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psnet.ahrq.gov/node/44782/psn-pdf
January 13, 2016 - The Swiss cheese model of adverse event
occurrence—closing the holes.
January 13, 2016
Stein JE, Heiss K. The Swiss cheese model of adverse event occurrence--Closing the holes. Semin Pediatr
Surg. 2015;24(6):278-82. doi:10.1053/j.sempedsurg.2015.08.003.
https://psnet.ahrq.gov/issue/swiss-cheese-model-adverse-event…
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psnet.ahrq.gov/node/45019/psn-pdf
April 27, 2016 - Effectiveness of surgical safety checklists in improving
patient safety.
April 27, 2016
Ragusa PS, Bitterman A, Auerbach B, et al. Effectiveness of Surgical Safety Checklists in Improving
Patient Safety. Orthopedics. 2016;39(2):e307-10. doi:10.3928/01477447-20160301-02.
https://psnet.ahrq.gov/issue/effectiveness-s…
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psnet.ahrq.gov/node/45987/psn-pdf
April 26, 2017 - Using simulation to prepare nursing staff for the move to
a new building.
April 26, 2017
Knippa S, Senecal P-A. Using Simulation to Prepare Nursing Staff for the Move to a New Building. J
Nurses Prof Dev. 2017;33(2):E1-E5. doi:10.1097/NND.0000000000000329.
https://psnet.ahrq.gov/issue/using-simulation-prepare-nurs…
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psnet.ahrq.gov/node/42961/psn-pdf
February 19, 2014 - Healthcare-associated infections: a national patient safety
problem and the coordinated response.
February 19, 2014
Jeeva RR, Wright D. Healthcare-associated infections: a national patient safety problem and the
coordinated response. Med Care. 2014;52(2 Suppl 1):S4-8. doi:10.1097/MLR.0b013e3182a54581.
https://psne…
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psnet.ahrq.gov/node/41633/psn-pdf
January 01, 2013 - Determinants of success of quality improvement
collaboratives: what does the literature show?
December 31, 2012
Hulscher M, Schouten LMT, Grol R, et al. Determinants of success of quality improvement collaboratives:
what does the literature show? BMJ Qual Saf. 2013;22(1):19-31. doi:10.1136/bmjqs-2011-000651.
https…
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psnet.ahrq.gov/node/41911/psn-pdf
December 12, 2012 - Effects of an intervention to increase bed alarm use to
prevent falls in hospitalized patients: a cluster
randomized trial.
December 12, 2012
Shorr RI, Chandler M, Mion LC, et al. Effects of an intervention to increase bed alarm use to prevent falls in
hospitalized patients: a cluster randomized trial. Ann Intern …
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psnet.ahrq.gov/node/50575/psn-pdf
October 23, 2019 - Dynamic pocket card for implementing ISBAR in shift
handover communication.
October 23, 2019
Schmidt T, Kocher DR, Mahendran P, et al. Dynamic Pocket Card for Implementing ISBAR in Shift
Handover Communication. Stud Health Technol Inform. 2019;267:224-229. doi:10.3233/SHTI190831.
https://psnet.ahrq.gov/issue/dynam…
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psnet.ahrq.gov/node/46742/psn-pdf
March 14, 2018 - Evidence-based guidelines for fatigue risk management in
emergency medical services.
March 14, 2018
Patterson D, Higgins S, Van Dongen HPA, et al. Evidence-Based Guidelines for Fatigue Risk Management
in Emergency Medical Services. Prehosp Emerg Care. 2018;22(sup1):89-101.
doi:10.1080/10903127.2017.1376137.
https…
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psnet.ahrq.gov/node/44843/psn-pdf
September 06, 2016 - Addressing the Global Shortages of Medicines, and the
Safety and Accessibility of Children's Medication.
September 6, 2016
Geneva, Switzerland: World Health Organization; 2015.
https://psnet.ahrq.gov/issue/addressing-global-shortages-medicines-and-safety-and-accessibility-childrens-
medication
Drug shortages have…
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psnet.ahrq.gov/node/35971/psn-pdf
May 27, 2011 - Effectiveness of computerized provider order entry with
dose range checking on prescribing errors.
May 27, 2011
Boling B, McKibben M, Hingl J, et al. Effectiveness of Computerized Provider Order Entry with Dose Range
Checking on Prescribing Errors. J Patient Saf. 2008;1(4). doi:10.1097/01.jps.0000215339.03807.fd.
…
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psnet.ahrq.gov/node/44014/psn-pdf
March 20, 2019 - Patient Centered Medical Home Resource Center: Quality
and Safety.
March 20, 2019
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/patient-centered-medical-home-resource-center-quality-and-safety
The Patient Centered Medical Home (PCMH) concept reorganizes primary care services to ensure th…
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psnet.ahrq.gov/node/43888/psn-pdf
August 02, 2015 - Diagnostic performance by medical students working
individually or in teams.
August 2, 2015
Hautz WE, Kämmer JE, Schauber SK, et al. Diagnostic performance by medical students working
individually or in teams. JAMA. 2015;313(3):303-4. doi:10.1001/jama.2014.15770.
https://psnet.ahrq.gov/issue/diagnostic-performance…
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psnet.ahrq.gov/node/48001/psn-pdf
May 22, 2019 - Medicines safety in anaesthetic practice.
May 22, 2019
Mackay E, Jennings J, Webber S. Medicines safety in anaesthetic practice. BJA Edu. 2019;19(5):151-157.
doi:10.1016/j.bjae.2019.01.001.
https://psnet.ahrq.gov/issue/medicines-safety-anaesthetic-practice
Human factors affect medication delivery in the operating …
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psnet.ahrq.gov/node/74118/psn-pdf
January 01, 2022 - From HRO to HERO: making health equity a core system
capability.
November 24, 2021
Moy E, Hausmann LRM, Clancy CM. From HRO to HERO: making health equity a core system capability.
Am J Med Qual. 2022;37(1):81-83. doi:10.1097/jmq.0000000000000020.
https://psnet.ahrq.gov/issue/hro-hero-making-health-equity-core-syst…
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psnet.ahrq.gov/node/37469/psn-pdf
January 16, 2008 - Towards the reduction of medication errors in
orthopedics and spinal surgery: outcomes using a
pharmacist-led approach.
January 16, 2008
Weiner BK, Venarske J, Yu M, et al. Towards the reduction of medication errors in orthopedics and spinal
surgery: outcomes using a pharmacist-led approach. Spine (Phila Pa 1976).…
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psnet.ahrq.gov/node/38068/psn-pdf
March 10, 2011 - The effect of electronic prescribing on medication errors
and adverse drug events: a systematic review.
March 10, 2011
Ammenwerth E, Schnell-Inderst P, Machan C, et al. The effect of electronic prescribing on medication
errors and adverse drug events: a systematic review. J Am Med Inform Assoc. 2008;15(5):585-600.
…
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June 06, 2025 - Let's Talk About It: Medicines to Help Prevent Breast Cancer Discussion Guide for Healthcare Providers and Patients
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www.ahrq.gov/patient-safety/about/national-steering-committee.html
June 01, 2021 - National Steering Committee for Patient Safety
YouTube embedded video: https://www.youtube-nocookie.com/embed/QUxyRDRTyLA
AHRQ is co-leading the National Steering Committee for Patient Safety, which includes members from two dozen organizations that are joining together to create a national action plan to ac…
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psnet.ahrq.gov/node/867449/psn-pdf
March 13, 2025 - Medication Related Harm.
March 13, 2025
Medication Related Harm. Health Services Safety Investigations Body. 2024-2025
https://psnet.ahrq.gov/issue/medication-related-harm
Omitted or delayed medication therapy can contribute to patient discomfort, stress, and harm. This series
of reports, to be developed over 2024…
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www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-interim-data-graphic-2014.pdf
January 01, 2014 - Patients Safer as Hospital-Acquired Conditions Decline (Data Graphic)
REDUCTION
IN HACs
REDUCTION
IN HACs
17%17%
LIVES SAVEDLIVES SAVED
87,00087,000
$$$
IN COSTS AVERTEDIN COSTS AVERTED
$19.8
BILLION
$19.8
BILLION
INSTANCES OF
HACs AVOIDED
INSTANCES OF
HACs AVOIDED
2.1
MILLION
2.1
MILLION
From 2010–2014, 1…