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psnet.ahrq.gov/node/45486/psn-pdf
September 14, 2016 - Addressing nurse fatigue to promote safety and health:
joint responsibilities of registered nurses and employers
to reduce risks.
September 14, 2016
Silver Spring, MD: American Nurses Association; September 2014.
https://psnet.ahrq.gov/issue/addressing-nurse-fatigue-promote-safety-and-health-joint-responsibilities…
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psnet.ahrq.gov/node/38945/psn-pdf
November 25, 2009 - The negative impact of nurse-physician disruptive
behavior on patient safety: a review of the literature.
November 25, 2009
Saxton R, Hines T, Enriquez M. The negative impact of nurse-physician disruptive behavior on patient
safety: a review of the literature. J Patient Saf. 2009;5(3):180-183. doi:10.1097/pts.0b013…
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psnet.ahrq.gov/node/839327/psn-pdf
December 05, 2024 - The National Healthcare System Action Alliance for
Patient and Workforce Safety.
December 5, 2024
US Department of Health and Human Services.
https://psnet.ahrq.gov/issue/national-healthcare-system-action-alliance-advance-patient-safety
The large system change required to reduce patient harm requires multi-stakeho…
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psnet.ahrq.gov/node/836761/psn-pdf
March 16, 2022 - Complexity bias in the prevention of iatrogenic injury:
why specific harms may inhibit performance.
March 16, 2022
Padula WV, Armstrong DG, Goldman DP. Complexity bias in the prevention of iatrogenic injury: why
specific harms may inhibit performance. Mayo Clin Proc. 2022;97(2):221-224.
doi:10.1016/j.mayocp.2021.1…
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psnet.ahrq.gov/node/47851/psn-pdf
May 22, 2019 - Communication and Resolution After an Adverse Health
Care Incident.
May 22, 2019
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
https://psnet.ahrq.gov/issue/communication-and-resolution-after-adverse-health-care-incident
Communication-and-resolution mechanisms are seen as important approache…
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psnet.ahrq.gov/node/40385/psn-pdf
May 21, 2019 - A comprehensive obstetrics patient safety program
improves safety climate and culture.
May 21, 2019
Pettker CM, Thung SF, Raab CA, et al. A comprehensive obstetrics patient safety program improves safety
climate and culture. Am J Obstet Gynecol. 2011;204(3):216.e1-6. doi:10.1016/j.ajog.2010.11.004.
https://psnet.a…
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psnet.ahrq.gov/node/46160/psn-pdf
June 07, 2017 - ISMP Guidelines for Optimizing Safe Subcutaneous
Insulin Use in Adults.
June 7, 2017
Horsham, PA: Institute for Safe Medication Practices; May 2017.
https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-subcutaneous-insulin-use-adults
Insulin is a widely used medication that can contribute to serious patien…
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psnet.ahrq.gov/node/855107/psn-pdf
January 01, 2019 - Foundations of Safety Science: a century of
understanding accidents and disasters.
January 1, 2019
Dekker S. Taylor & Francis Group, Boca Raton, FL: CRC Press; 2019. ISBN: 9781138481787.
https://psnet.ahrq.gov/issue/foundations-safety-science-century-understanding-accidents-and-disasters
Safety science p…
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psnet.ahrq.gov/node/47718/psn-pdf
March 20, 2019 - Impact of patient safety culture on missed nursing care
and adverse patient events.
March 20, 2019
Hessels AJ, Paliwal M, Weaver SH, et al. Impact of Patient Safety Culture on Missed Nursing Care and
Adverse Patient Events. J Nurs Care Qual. 2019;34(4):287-294. doi:10.1097/NCQ.0000000000000378.
https://psnet.ahrq.…
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digital.ahrq.gov/ahrq-funded-projects/enabling-shared-decision-making-reduce-harm-drug-interactions-end-end/citation/coordinated
January 01, 2023 - Coordinated use of Health Level 7 standards to support clinical decision support: Case study with shared decision making and drug-drug interactions.
Citation
Thiess H, Del Fiol G, Malone DC, Cornia R, Sibilla M, Rhodes B, Boyce RD, Kawamoto K, Reese T. Coordinated use of Health Level 7 standards to su…
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integrationacademy.ahrq.gov/print/pdf/node/23255
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Website
https://bipartisanpolicy.org/?query=behavioral%20health%20integration
Mission
To build connections, negotiate policy, achieve bipartisan solutions, and improve lives.
Location
Washington, DC
United States
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Description
A nonprofit that ensures p…
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www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/lets-talk-about-it-discussion-guides/lets-talk-about-it-medicines-help-prevent-breast-cancer-discussion-guide-healthcare-providers-and-patients
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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psnet.ahrq.gov/node/867701/psn-pdf
August 01, 2017 - Toolkit To Improve Safety for Mechanically Ventilated
Patients.
August 1, 2017
Agency for Healthcare Research and Quality . Toolkit To Improve Safety for Mechanically Ventilated
Patients. August 2017.
https://psnet.ahrq.gov/issue/toolkit-improve-safety-mechanically-ventilated-patients
Patients requiring mechanica…
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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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psnet.ahrq.gov/node/72751/psn-pdf
February 17, 2021 - The critical need for nursing education to address the
diagnostic process.
February 17, 2021
Gleason KT, Harkless G, Stanley J, et al. The critical need for nursing education to address the diagnostic
process. Nurs Outlook. 2021;69(3):362-369. doi:10.1016/j.outlook.2020.12.005.
https://psnet.ahrq.gov/issue/critica…
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psnet.ahrq.gov/node/47943/psn-pdf
May 20, 2019 - Governing the safety of artificial intelligence in
healthcare.
May 20, 2019
Macrae C. Governing the safety of artificial intelligence in healthcare. BMJ Qual Saf. 2019;28(6):495-498.
doi:10.1136/bmjqs-2019-009484.
https://psnet.ahrq.gov/issue/governing-safety-artificial-intelligence-healthcare
The unintended risk…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.350_slideshow.ppt
June 01, 2015 - PowerPoint Presentation
Spotlight
Anchoring Bias With Critical Implications
1
This presentation is based on the June 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Edward Etchells, MD, MSc, Division of General Internal Medicine, Centre for Q…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/safe-medication-slides.html
July 01, 2023 - Safe Medication Administration: Slide Presentation
AHRQ Safety Program for Perinatal Care
Slide 1: AHRQ Safety Program for Perinatal Care
Safe Medication Administration
Slide 2: Learning Objectives
Image: Four ascending steps show the learning objectives:
Define high-alert medications.
Identif…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-203-section-2-tech-specs.pdf
December 14, 2011 - Chart Abstraction Form
Basic Elements
Patient ID Race Ethnicity Gender Payer
Preferred
Language
Age upon
admission (YEARS)
[e.g. for 12.5 year
old, years = 12)
Age upon
admission
(MONTHS) [ e.g.
for 12.5 year old,
months = 6]
1 White Non-Hispanic Female Medicaid English …
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www.ahrq.gov/hai/cauti-tools/archived-webinars/mindfulness-slides.html
December 01, 2017 - Mindfulness: Engaging Frontline Providers in Antimicrobial Stewardship
Slide Presentation
Slide 1
Mindfulness: Engaging Frontline Providers in Antimicrobial Stewardship
CAPT Arjun Srinivasan, MD
Associate Director for Healthcare
Associated Infection Prevention Programs
Division of Healthcare Quality …