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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/creative-education-rapid-response-team-implementation
October 13, 2018 - Commentary
Creative education for rapid response team implementation.
Citation Text:
Johnson AL. Creative education for rapid response team implementation. J Contin Educ Nurs. 2009;40(1):38-42.
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psnet.ahrq.gov/issue/medication-mix-what-happened-vanderbilt-and-how-it-impacts-health-care-providers
March 18, 2020 - Commentary
Medication mix-up: what happened at Vanderbilt and how it impacts health care providers.
Citation Text:
Medication mix-up: what happened at Vanderbilt and how it impacts health care providers. Michel C, Talley C. J Health Life Sci Law. 2022;17(1):71
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psnet.ahrq.gov/issue/embedding-quality-and-safety-otolaryngology-head-and-neck-surgery-education
August 11, 2010 - Commentary
Embedding quality and safety in otolaryngology–head and neck surgery education.
Citation Text:
McCormick ME, Stadler ME, Shah RK. Embedding quality and safety in otolaryngology-head and neck surgery education. Otolaryngol Head Neck Surg. 2015;152(5):778-782. doi:10.1177/019459…
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psnet.ahrq.gov/issue/assessing-teamwork-and-communication-authentic-patient-care-learning-environment
July 02, 2014 - Commentary
Assessing teamwork and communication in the authentic patient care learning environment.
Citation Text:
Haftel HM, Hicks PJ. Assessing teamwork and communication in the authentic patient care learning environment. Pediatrics. 2011;127(4):601-3. doi:10.1542/peds.2010-3767.
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psnet.ahrq.gov/issue/respectful-trusting-relationships-are-essential-patient-safety-especially-surgeon
December 08, 2024 - Meeting/Conference Proceedings
Respectful, trusting relationships are essential for patient safety, especially the surgeon-anesthesiologist dyad.
Citation Text:
Respectful, trusting relationships are essential for patient safety, especially the surgeon-anesthesiologist dyad. Cooper J. An…
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psnet.ahrq.gov/issue/tension-between-promoting-mobility-and-preventing-falls-hospital
April 24, 2018 - Commentary
The tension between promoting mobility and preventing falls in the hospital.
Citation Text:
Growdon ME, Shorr RI, Inouye SK. The Tension Between Promoting Mobility and Preventing Falls in the Hospital. JAMA Intern Med. 2017;177(6):759-760. doi:10.1001/jamainternmed.2017.0840. …
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psnet.ahrq.gov/issue/negotiating-safety-when-staffing-falls-short
October 19, 2022 - Commentary
Negotiating safety when staffing falls short.
Citation Text:
Zolnierek CD, Steckel CM. Negotiating Safety when Staffing Falls Short. Crit Care Nurs Clin North Am. 2010;22(2). doi:10.1016/j.ccell.2010.03.014.
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psnet.ahrq.gov/issue/patient-safety-organizations-hospital-participation-value-and-challenges
February 11, 2015 - Book/Report
Patient Safety Organizations: Hospital Participation, Value, and Challenges.
Citation Text:
Patient Safety Organizations: Hospital Participation, Value, and Challenges. US Department of Health and Human Services; Office of the Inspector General, September 2019. OIG Report N…
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psnet.ahrq.gov/issue/ranking-rate-state-medical-boards-serious-disciplinary-actions-2019-2021
October 05, 2016 - Book/Report
Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions, 2019-2021.
Citation Text:
Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions, 2019-2021. Wolfe SW, Oshel RE. Washington, DC: Public Citizen; August 16, 2023.
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www.ahrq.gov/sops/surveys/nursing-home/index.html
April 01, 2025 - SOPS Nursing Home Survey
AHRQ released the Surveys on Patient Safety Culture® (SOPS®) Nursing Home Survey to assess staff perceptions about patient safety culture in their nursing home in 2008. In 2025, AHRQ released a new version, the SOPS Nursing Home Survey 2.0 . This new version removed all negatively wo…
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psnet.ahrq.gov/issue/telemedicine-ensuring-safe-equitable-person-centered-virtual-care
March 29, 2006 - Book/Report
Telemedicine: Ensuring Safe, Equitable, Person-Centered Virtual Care.
Citation Text:
Telemedicine: Ensuring Safe, Equitable, Person-Centered Virtual Care. Perry AF, Federico F, Huebner J. Boston, MA: Institute for Healthcare Improvement; 2021.
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psnet.ahrq.gov/issue/respectful-management-serious-clinical-adverse-events-second-edition
January 27, 2016 - Book/Report
Classic
Respectful Management of Serious Clinical Adverse Events. Second Edition.
Citation Text:
Respectful Management of Serious Clinical Adverse Events. Second Edition. Conway J, Federico F, Stewart K, Campbell MJ. Cambridge, MA: Institute for Heal…
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psnet.ahrq.gov/issue/economics-patient-safety-part-iii-long-term-care-valuing-safety-long-haul
September 28, 2022 - Book/Report
The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul.
Citation Text:
The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul. de Bienassis K, Llena-Nozal A, Klazinga N for the Organisation for Econo…
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psnet.ahrq.gov/issue/maryland-hospital-patient-safety-program-annual-report
December 24, 2008 - Book/Report
Maryland Hospital Patient Safety Program Annual Report.
Citation Text:
Maryland Hospital Patient Safety Program Annual Report. Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene.
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psnet.ahrq.gov/issue/using-medical-malpractice-closed-claims-data-reduce-surgical-risk-and-improve-patient-safety
December 01, 2010 - Commentary
Using medical malpractice closed claims data to reduce surgical risk and improve patient safety.
Citation Text:
Manuel BM, Greenwald LM. Using medical malpractice closed claims data to reduce surgical risk and improve patient safety. Bull Am Coll Surg. 2007;92(3):27-30.
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www.ahrq.gov/news/newsletters/e-newsletter/915.html
June 01, 2024 - set of teamwork tools aimed at optimizing patient outcomes by improving communication and teamwork skills
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digital.ahrq.gov/ahrq-funded-projects/enabling-medication-management-through-utilization-health-information/annual-summary/2010
January 01, 2010 - Improvements in use, knowledge, skills, and attitudes were also found to be associated with MMIT systems
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP-Patient-Family-Engagement.pptx
May 01, 2013 - 6
Characteristics of an
Engaged Advisor1
Listen well
Share your views
Draw on your communication skills
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-indications.pptx
April 01, 2022 - Insertion versus downstream risks
Types of complications vary
Infectious versus thrombotic
Provider skills