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psnet.ahrq.gov/issue/paramedic-intubation-errors-isolated-events-or-symptoms-larger-problems
February 18, 2009 - Study
Paramedic intubation errors: isolated events or symptoms of larger problems?
Citation Text:
Wang HE, Lave J, Sirio CA, et al. Paramedic intubation errors: isolated events or symptoms of larger problems? Health Aff (Millwood). 2006;25(2):501-9.
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psnet.ahrq.gov/issue/need-organizational-change-patient-safety-initiatives
May 12, 2010 - Study
The need for organizational change in patient safety initiatives.
Citation Text:
Anderson J, Ramanujam R, Hensel D, et al. The need for organizational change in patient safety initiatives. Int J Med Inform. 2006;75(12):809-17.
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psnet.ahrq.gov/issue/postpartum-hemorrhage-patient-safety-bundle-implementation-single-institution-successes
February 01, 2023 - Study
The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures, and lessons learned,
Citation Text:
Duzyj CM, Boyle C, Mahoney K, et al. The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, f…
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psnet.ahrq.gov/node/37419/psn-pdf
December 19, 2007 - Ensuring medication reconciliation.
December 19, 2007
Georgia K, Kinney K, Pace A, Helton K. Patient Saf Qual Healthc. November / December 2007.
https://psnet.ahrq.gov/issue/ensuring-medication-reconciliation
The authors describe the team-based process they used to improve medication management at the
admission, t…
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psnet.ahrq.gov/issue/ssssh-handover-protected-medical-handover-optimising-quality-and-prioritising-safety-regional
March 08, 2017 - Commentary
Ssssh for handover: protected medical handover; optimising quality and prioritising safety—a regional initiative.
Citation Text:
Mallett P, Thompson A, Bourke T, et al. Ssssh for Handover: protected medical handover; optimising quality and prioritising safety-a regional initia…
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psnet.ahrq.gov/node/856640/psn-pdf
November 29, 2023 - Research from webAIRS incident reporting system.
November 29, 2023
Anaesth Intensive Care. 2023;51(6):372-421.
https://psnet.ahrq.gov/issue/research-webairs-incident-reporting-system
Centralized de-identified reports of patient safety events serve a core purpose for learning and
improvement. This article collectio…
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psnet.ahrq.gov/node/37407/psn-pdf
September 02, 2014 - HSMR: A New Approach for Measuring Hospital Mortality
Trends in Canada.
September 2, 2014
Ottowa, Ontario, CA: Canadian Institute for Health Information; 2007. ISBN 9781554651832.
https://psnet.ahrq.gov/issue/hsmr-new-approach-measuring-hospital-mortality-trends-canada
This report describes a new metric used to an…
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psnet.ahrq.gov/node/35823/psn-pdf
July 20, 2010 - Renewal of surgical quality and safety initiatives: a
multispecialty challenge.
July 20, 2010
Polk HC. Renewal of surgical quality and safety initiatives: a multispecialty challenge. Mayo Clin Proc.
2006;81(3):345-52.
https://psnet.ahrq.gov/issue/renewal-surgical-quality-and-safety-initiatives-multispecialty-chall…
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psnet.ahrq.gov/node/35001/psn-pdf
May 22, 2009 - 21st Century Health Information Act of 2005.
May 22, 2009
Murphy T; Kennedy P.
https://psnet.ahrq.gov/issue/21st-century-health-information-act-2005
This bill, which garnered bipartisan support, proposes developing health information technology networks
(known as "Regional Health Information Organizations," or RHI…
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psnet.ahrq.gov/node/850343/psn-pdf
December 12, 2023 - Challenge Competition: Impact of Patient Safety Tools.
December 12, 2023
Rockville, MD: Agency for Healthcare Research and Quality; 2023.
https://psnet.ahrq.gov/issue/challenge-competition-impact-patient-safety-tools
The Agency for Healthcare Research and Quality (AHRQ) offers many practical tools and resource…
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psnet.ahrq.gov/training-catalog/northwest-patient-safety-conference
Northwest Patient Safety Conference
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Organization:
Organization
Washington Patient Safety Coalition (WPSC)
Event Description: This y…
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psnet.ahrq.gov/node/40848/psn-pdf
October 12, 2011 - IBEAS: A Pioneer Study on Patient Safety in Latin
America: Towards Safer Hospital Care.
October 12, 2011
Geneva, Switzerland: World Health Organization; 2011.
https://psnet.ahrq.gov/issue/ibeas-pioneer-study-patient-safety-latin-america-towards-safer-hospital-care
This publication reports on the findings of…
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psnet.ahrq.gov/node/40572/psn-pdf
June 27, 2018 - Understanding care transitions as a patient safety issue.
June 27, 2018
Butterfield S; Stegel C; Glock S; Tartaglia D.
https://psnet.ahrq.gov/issue/understanding-care-transitions-patient-safety-issue
This article describes a regional collaborative to enhance care transitions of Medicare beneficiaries by
improving …
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psnet.ahrq.gov/node/42576/psn-pdf
September 04, 2013 - Exploring Patient Engagement in Reducing Health-Care-
Related Safety Risks.
September 4, 2013
Copenhagen, Denmark: World Health Organization Regional Office for Europe; 2013. ISBN:
9789289002943.
https://psnet.ahrq.gov/issue/exploring-patient-engagement-reducing-health-care-related-safety-risks
Exploring th…
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psnet.ahrq.gov/Topics
February 26, 2021 - Topics
Featured topics
Ordering/Prescribing Errors
Mental Health Care (Psychiatry & Clinical Psychology)
Health Literacy Improvement
Structured Hand-offs
Popular topics
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psnet.ahrq.gov/topics
March 17, 2021 - Topics
Featured topics
Ordering/Prescribing Errors
Mental Health Care (Psychiatry & Clinical Psychology)
Health Literacy Improvement
Structured Hand-offs
Popular topics
…
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psnet.ahrq.gov/node/37602/psn-pdf
July 03, 2013 - The vanishing nonforensic autopsy.
July 3, 2013
Shojania KG, Burton EC. The vanishing nonforensic autopsy. N Engl J Med. 2008;358(9):873-5.
doi:10.1056/NEJMp0707996.
https://psnet.ahrq.gov/issue/vanishing-nonforensic-autopsy
Autopsies are rarely performed, despite a wealth of literature demonstrating that diagnost…
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psnet.ahrq.gov/issue/why-do-we-still-page-each-other-examining-frequency-types-and-senders-pages-academic-medical
September 11, 2019 - Study
Why do we still page each other? Examining the frequency, types and senders of pages in academic medical services.
Citation Text:
Carlile N, Rhatigan JJ, Bates DW. Why do we still page each other? Examining the frequency, types and senders of pages in academic medical services. BMJ…
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psnet.ahrq.gov/node/73973/psn-pdf
October 13, 2021 - Agency information collection activities: National
Healthcare Safety Network (NHSN); comment request.
October 13, 2021
Zirger JM, Centers for Disease Control and Prevention. Fed Register. September 27,
2021;86:53309-53312.
https://psnet.ahrq.gov/issue/agency-information-collection-activities-national-healthca…
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psnet.ahrq.gov/node/37713/psn-pdf
June 07, 2008 - Giving back the pen: disclosure, apology and early
compensation discussions after harm in the healthcare
setting.
June 7, 2008
Pelletier E, Robson. Healthc Q. 2008;11(3 Spec No):85-90.
https://psnet.ahrq.gov/issue/giving-back-pen-disclosure-apology-and-early-compensation-discussions-after-
harm-healthcare
This c…