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psnet.ahrq.gov/improvement-tools
February 26, 2025 - Improvement Resources Overview
Patient Safety Innovations highlight important innovations that can lead to improvements in patient safety, while Toolkits provide the practical applications of PSNet research and concepts for front line providers to use in their day to day work. Together these support the implementatio…
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psnet.ahrq.gov/node/49744/psn-pdf
October 01, 2015 - 170.314 (b)(1) Transitions of care—receive, display and incorporate transition of
care/referral summaries
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psnet.ahrq.gov/node/43853/psn-pdf
March 11, 2015 - Expressing concern and writing it down: an experimental
study investigating transfer of information at nursing
handover.
March 11, 2015
Lee H, Cumin D, Devcich DA, et al. Expressing concern and writing it down: an experimental study
investigating transfer of information at nursing handover. J Adv Nurs. 2015;71(1):…
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psnet.ahrq.gov/issue/delivering-high-quality-cancer-care-charting-new-course-system-crisis
August 15, 2012 - Book/Report
Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.
Citation Text:
Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Levit L, Balogh E, Nass S, Ganz PA, eds. Committee on Improving the Quality of Cancer Care: Add…
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psnet.ahrq.gov/issue/unequal-treatment-confronting-racial-and-ethnic-disparities-health-care
June 15, 2011 - Book/Report
Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.
Citation Text:
Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Smedley BD, Stith AY, Nelson AR, eds and Institute of Medicine. Washington, DC; The National Academies Pres…
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psnet.ahrq.gov/issue/executive-summary-american-college-obstetricians-and-gynecologists-presidential-task-force
September 23, 2020 - Commentary
Executive summary of the American College of Obstetricians and Gynecologists Presidential Task Force on Patient Safety in the Office Setting: reinvigorating safety in office-based gynecologic surgery.
Citation Text:
Erickson TB, Kirkpatrick DH, DeFrancesco MS, et al. Executi…
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psnet.ahrq.gov/issue/incorporating-health-information-technology-workflow-redesign-request-information-summary
September 29, 2017 - Book/Report
Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary Report.
Citation Text:
Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary Report. Carayon P, Karsh B-T, Cartmill RS, et al.…
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psnet.ahrq.gov/issue/25-year-summary-us-malpractice-claims-diagnostic-errors-1986-2010-analysis-national
July 17, 2019 - Study
25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank.
Citation Text:
Tehrani ASS, Lee HW, Mathews SC, et al. 25-Year summary of US malpractice claims for diagnostic errors 1986-2010: an analysis from the N…
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psnet.ahrq.gov/node/867845/psn-pdf
February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step
Technique Innovation Summary
February 26, 2025
https://psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-
summary
Summary
This innovation describes the Veteran Health Administration (VHA) National Center for Patient Saf…
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psnet.ahrq.gov/node/854641/psn-pdf
October 18, 2023 - Ranking of the Rate of State Medical Boards’ Serious
Disciplinary Actions, 2019-2021.
October 18, 2023
Wolfe SW, Oshel RE. Washington, DC: Public Citizen; August 16, 2023.
https://psnet.ahrq.gov/issue/ranking-rate-state-medical-boards-serious-disciplinary-actions-2019-2021
There are recognized systemic w…
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psnet.ahrq.gov/issue/health-it-and-patient-safety-building-safer-systems-better-care
June 16, 2011 - Book/Report
Classic
Health IT and Patient Safety: Building Safer Systems for Better Care.
Citation Text:
Health IT and Patient Safety: Building Safer Systems for Better Care. Committee on Patient Safety and Health Information Technology, Board on Health Care Ser…
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psnet.ahrq.gov/print/pdf/node/74279
January 01, 2022 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
COVID-19 Pandemic Impact on Healthcare
Associated Conditions
Curated Library
All Library Content
The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a
summary of data reported to the National Healt…
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psnet.ahrq.gov/node/60190/psn-pdf
April 01, 2020 - Potentially Preventable Readmissions: Conceptual
Framework To Rethink the Role of Primary Care.
Executive Summary.
April 1, 2020
Maxwell J, Bourgoin A, Crandall J. Potentially Preventable Readmissions: Conceptual Framework To
Rethink The Role Of Primary Care. Executive Summary. Rockville, MD : Agency for Healthcar…
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psnet.ahrq.gov/issue/impact-coronavirus-disease-2019-covid-19-healthcare-associated-infections-2020-summary-data
February 07, 2022 - Study
The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a summary of data reported to the National Healthcare Safety Network.
Citation Text:
Weiner-Lastinger LM, Pattabiraman V, Konnor RY, et al. The impact of coronavirus disease 2019 (COVID-1…
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psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
January 07, 2015 - Misconnection Leading to Arterial Thrombosis
June 28, 2023
Danger in discharge summaries
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psnet.ahrq.gov/web-mm/dressed-failure
September 01, 2011 - physicians includes medication data, laboratory data, imaging files, clinical documentation, discharge summaries
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psnet.ahrq.gov/node/49612/psn-pdf
November 01, 2010 - Adequacy of hospital discharge summaries in documenting tests with
pending results and outpatient follow-up
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psnet.ahrq.gov/web-mm/hold-order
December 19, 2018 - These summaries could include both active and recently discontinued medications.
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psnet.ahrq.gov/node/867037/psn-pdf
January 01, 2025 - Medicine communication from hospital to residential aged
care facilities: a cross-sectional survey of aged care
facility staff.
October 30, 2024
Browning S, Raleigh RA, Hattingh HL. Medicine communication from hospital to residential aged care
facilities: a cross-sectional survey of aged care facility staff. Int J…
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psnet.ahrq.gov/issue/acgme-summary-report-pursuing-excellence-pathway-leaders-patient-safety-collaborative
October 18, 2017 - Book/Report
ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient Safety Collaborative.
Citation Text:
ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient Safety Collaborative. Passiment M, Wagner R, Weiss KB for the Pursuing Excellence in Clinical Learn…