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psnet.ahrq.gov/issue/keeping-patients-safe-healthcare-organizations-structuration-theory-safety-culture
September 04, 2010 - Review
Keeping patients safe in healthcare organizations: a structuration theory of safety culture.
Citation Text:
Groves PS, Meisenbach RJ, Scott-Cawiezell J. Keeping patients safe in healthcare organizations: a structuration theory of safety culture. J Adv Nurs. 2011;67(8):1846-55. d…
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psnet.ahrq.gov/issue/judging-whether-patient-actually-improving-more-pitfalls-science-human-perception
September 04, 2019 - Review
Judging whether a patient is actually improving: more pitfalls from the science of human perception.
Citation Text:
Redelmeier DA, Dickinson VM. Judging whether a patient is actually improving: more pitfalls from the science of human perception. J Gen Intern Med. 2012;27(9):1195-9…
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psnet.ahrq.gov/issue/improving-care-using-patient-feedback
April 19, 2017 - Book/Report
Improving care by using patient feedback.
Citation Text:
Improving care by using patient feedback. National Institute for Health Research. Southampton, UK: NIHR Dissemination Centre; December 2019.
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psnet.ahrq.gov/issue/standardization-inpatient-handoff-communication
April 26, 2023 - Organizational Policy/Guidelines
Standardization of inpatient handoff communication.
Citation Text:
Jewell JA. Standardization of Inpatient Handoff Communication. Pediatrics. 2016;138(5):e20162681. doi:10.1542/peds.2016-2681.
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psnet.ahrq.gov/issue/4-actions-reduce-medical-errors-us-hospitals
July 24, 2024 - Newspaper/Magazine Article
4 actions to reduce medical errors in U.S. hospitals.
Citation Text:
4 actions to reduce medical errors in U.S. hospitals. Toussaint JS, Segel KT. Harvard Business Review. April 20, 2022.
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psnet.ahrq.gov/issue/effect-nurse-staffing-patterns-medical-errors-and-nurse-burnout
October 11, 2023 - Review
The effect of nurse staffing patterns on medical errors and nurse burnout.
Citation Text:
Garrett C. The effect of nurse staffing patterns on medical errors and nurse burnout. AORN J. 2008;87(6):1191-204. doi:10.1016/j.aorn.2008.01.022.
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psnet.ahrq.gov/issue/iatrogenic-harm-cost-equation-and-new-technology
January 24, 2024 - Commentary
The iatrogenic-harm cost equation and new technology.
Citation Text:
Webster CS. The iatrogenic-harm cost equation and new technology. Anaesthesia. 2005;60(9). doi:10.1111/j.1365-2044.2005.04331.x.
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psnet.ahrq.gov/issue/system-related-factors-contributing-diagnostic-errors
January 11, 2023 - Review
System-related factors contributing to diagnostic errors.
Citation Text:
Thammasitboon S, Thammasitboon S, Singhal G. System-related factors contributing to diagnostic errors. Curr Probl Pediatr Adolesc Health Care. 2013;43(9):242-7. doi:10.1016/j.cppeds.2013.07.004.
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psnet.ahrq.gov/issue/understanding-human-factors-patient-safety-when-prescribing
June 15, 2022 - Newspaper/Magazine Article
Understanding human factors in patient safety when prescribing.
Citation Text:
Coon R, Holden K. Understanding human factors in patient safety when prescribing. Pharmaceutical Journal. September 2024;313(7989).
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psnet.ahrq.gov/issue/concept-analysis-wrong-site-surgery
June 11, 2014 - Review
Concept analysis: wrong-site surgery.
Citation Text:
Watson DS. Concept analysis: wrong-site surgery. AORN J. 2015;101(6):650-6. doi:10.1016/j.aorn.2015.03.012.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
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psnet.ahrq.gov/issue/requirements-design-and-implementation-checklists-surgical-processes
September 25, 2008 - Review
Requirements for the design and implementation of checklists for surgical processes.
Citation Text:
Verdaasdonk EGG, Stassen LPS, Widhiasmara PP, et al. Requirements for the design and implementation of checklists for surgical processes. Surg Endosc. 2009;23(4):715-26. doi:10.10…
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psnet.ahrq.gov/issue/how-avoid-paediatric-medication-errors-users-guide-literature
May 26, 2011 - Review
How to avoid paediatric medication errors: a user's guide to the literature.
Citation Text:
Walsh KE, Kaushal R, Chessare JB. How to avoid paediatric medication errors: a user's guide to the literature. Arch Dis Child. 2005;90(7):698-702.
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psnet.ahrq.gov/issue/drug-shortages-0
February 22, 2023 - Review
Drug shortages.
Citation Text:
Drug shortages. Aronson JK, Heneghan C, Ferner RE. Br J Clin Pharmacol. 2023;89(10):2950-2963.
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psnet.ahrq.gov/issue/patient-safety-latent-risk-factors
March 28, 2011 - Review
Patient safety: latent risk factors.
Citation Text:
van Beuzekom M, Boer F, Akerboom S, et al. Patient safety: latent risk factors. Br J Anaesth. 2010;105(1):52-9. doi:10.1093/bja/aeq135.
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psnet.ahrq.gov/issue/office-based-anesthesia-new-frontiers-better-outcomes-and-emphasis-safety
March 10, 2011 - Review
Office-based anesthesia: new frontiers, better outcomes, and emphasis on safety.
Citation Text:
Desai MS. Office-based anesthesia: new frontiers, better outcomes, and emphasis on safety. Curr Opin Anaesthesiol. 2008;21(6):699-703. doi:10.1097/ACO.0b013e328313e879.
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psnet.ahrq.gov/issue/computerized-provider-order-entry-and-prescribing-and-evidence-safe-practice-update-clinical
November 03, 2015 - Review
Computerized provider order entry and prescribing and the evidence for safe practice: update for the clinical nurse specialist.
Citation Text:
O'Malley P. Computerized provider order entry and prescribing and the evidence for safe practice: update for the clinical nurse speciali…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d1_pdi_improvementmethodsoverview.pptx
June 02, 2025 - PowerPoint Presentation
Use these PowerPoint slides for any presentations for which they may be useful.
These slides may be useful earlier on in the process than during implementation; feel free to use them at any point in your QI process.
Modify as needed to suit your hospital – you may wish to delete sections of sl…
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psnet.ahrq.gov/issue/obstetric-care-consensus-no-5-severe-maternal-morbidity-screening-and-review
August 20, 2018 - Organizational Policy/Guidelines
Obstetric Care Consensus No. 5: Severe Maternal Morbidity: Screening and Review.
Citation Text:
Obstetric Care Consensus No. 5: Severe Maternal Morbidity: Screening and Review. Obstet Gynecol. 2016;128(3):e54-60. doi:10.1097/AOG.0000000000001642.
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psnet.ahrq.gov/issue/simulation-obstetric-anesthesia
January 12, 2011 - Review
Simulation in obstetric anesthesia.
Citation Text:
Pratt SD. Focused review: simulation in obstetric anesthesia. Anesth Analg. 2012;114(1):186-90. doi:10.1213/ANE.0b013e3182377bbc.
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www.ahrq.gov/hai/tools/mrsa-prevention/surgery/science-of-safety.html
April 01, 2025 - MRSA Prevention Toolkit: Targeting SSI
The Science of Safety: Principles in Practice
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Table of Contents
MRSA Prevention Toolkit: Targeting SSI
The Four Key Strategies of MRSA Prevention: Targeting SSI
MRSA and SSI Prevention Phases
The Evidence for MRSA Decolonization
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