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psnet.ahrq.gov/issue/toward-learning-patient-safety-reporting-systems
January 02, 2017 - developed through funding by the Agency for Healthcare Research and Quality (AHRQ), collected data on … June 29, 2009
Intensive care unit safety incidents for medical versus surgical patients … June 15, 2011
How will we know patients are safer? … April 13, 2022
The effect of an electronic SBAR communication tool on documentation of … November 17, 2010
Adverse drug event reporting in intensive care units: a survey of current
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psnet.ahrq.gov/issue/buried-answers
May 11, 2005 - October 21, 2015
In a culture of disrespect, patients lose out. … July 3, 2013
Checking the right boxes, but failing the patient. … May 4, 2015
Patient safety in the ED. … December 20, 2006
Clinical Lab Quality: CMS and Survey Organization Oversight Should … Topic
Physicians
Facility and Group Administrators
Quality and Safety Professionals
Patients
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
March 24, 2025 - A leading expert on disclosure and the psychological impact of medical errors on both patients and caregivers … I wanted to fill in your survey, but I just couldn't." … Every survey suggests that even though people need support, they usually don't get it. … It's really interesting that both patients and providers very early on are interested in knowing what … But we do need to hang on to people who really care about their patients' welfare.
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psnet.ahrq.gov/issue/independent-double-checks-worth-effort-if-used-judiciously-and-properly
January 23, 2019 - Independent double checks can reduce risk of human error as a contributor to patient harm. … This newsletter article reports on how double checks can prevent medication administration mistakes … January 23, 2019
Results of survey on pediatric medication safety—part 1 and part 2. … May 7, 2018
Partnering with families and patient advocates: another line of defense in … November 5, 2014
JCAHO tightens leash on medication reconciliation.
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psnet.ahrq.gov/issue/medication-errors-2023-year-review-january-through-december
February 21, 2024 - Resources From the Same Author(s)
Health tech hazards: at-home medical devices, AI governance on … January 14, 2019
I-PASS checklist: a powerful tool for patient handoffs. … May 20, 2020
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Related Resources
Survey results reveal … July 1, 2020
Annual Perspective
Pharmacist Role in Patient
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psnet.ahrq.gov/issue/delivering-high-reliability-maternity-care-situ-simulation-source-organisational-resilience
April 05, 2023 - Acting wisely in complex clinical situations: 'Mutual safety' for clinicians as well as patients … October 13, 2021
Detach yourself: the positive effect of psychological detachment on … patient safety in long-term care. … October 13, 2021
A qualitative survey of factors shaping the role of a safety professional … 2021
In-situ interprofessional perinatal drills: the impact of a structured debrief on
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psnet.ahrq.gov/issue/day-passes-vulnerable-patients-psychiatric-hospitals-can-have-dangerous-even-fatal
October 29, 2014 - Psychiatric patients are vulnerable to particular safety hazards . … This news article reports on unintended consequences associated with a strategy to help patients adapt … February 11, 2014
Surgical fires: decreasing incidence relies on continued prevention … Engagement of leadership in quality improvement initiatives: executive quality improvement survey … November 9, 2022
Their kids died on the psych ward.
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psnet.ahrq.gov/node/49698/psn-pdf
December 01, 2013 - On arrival to the SNF, the patient
was on 14 medications for her various conditions and remained mildly … The SNF physician saw the patient on the first day but not
after that time. … , present in up to 40% of post-acute patients and
associated with poor outcomes.(3) This patient is … Strategies to Improve Patient Safety in Managing Complex Post-Acute Patients in the SNF
Setting.
… on
Patient Safety
Culture allows
facilities to enter
and benchmark
data on safety
culture
http
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psnet.ahrq.gov/issue/shortage-everything-except-errors-harm-associated-drug-shortages
February 13, 2019 - This article reports results from a survey of hospital pharmacy staff on patient injury associated with … Related Resources From the Same Author(s)
Just Culture and its critical link to patient … , 2018
Raising the index of suspicion: red flags that represent credible threats to patient … June 10, 2018
Side tracks on the safety express. … September 12, 2016
Impact of drug shortages on U.S. health systems.
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psnet.ahrq.gov/issue/few-hospitals-are-willing-bear-cost-providing-psychiatric-care-kids
March 15, 2023 - Pediatric mental health is a patient safety concern . … news story outlines the challenges to available services to address this need, tactics to keep young patients … Related Resources From the Same Author(s)
AMA Prior Authorization (PA) Physician Survey … June 23, 2021
Safe clinical practice for patients hospitalised in mental health wards … during a suicidal crisis: qualitative study of patient experiences.
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psnet.ahrq.gov/issue/through-eyes-workforce-creating-joy-meaning-and-safer-health-care
November 23, 2016 - Roundtable on Joy and Meaning in Work and Workforce Safety, The Lucian Leape Institute. … Facebook
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January 6, 2015
Roundtable on … Roundtable on Joy and Meaning in Work and Workforce Safety, The Lucian Leape Institute. … Related Resources From the Same Author(s)
Safety Is Personal: Partnering With Patients … Psychological Safety Scale of the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey
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psnet.ahrq.gov/issue/competent-surgeon-individual-accountability-era-systems-failure
May 30, 2014 - October 25, 2010
Closing the loop: follow-up and feedback in a patient safety program … March 3, 2011
The impact of professionalism on safe surgical care. … March 13, 2019
Diagnosing sepsis is subjective and highly variable: a survey of intensivists … July 5, 2016
Intravenous chemotherapy preparation errors: patient safety risks identified … opioid prescribing and patient pain in opioid-naive patients undergoing elective surgery in a large
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psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd
March 24, 2025 - We focused on how patients could provide feedback on patient safety. … Some studies in the States had looked at whether patients were able to report on patient safety incidents … Patients have a unique perspective on the care environment and provide feedback on that, which can be … We developed a questionnaire that asked patients about the factors that contribute to patient safety … As you said, this might be measurements of staff safety culture or it might be a measure of incident
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psnet.ahrq.gov/issue/another-fatal-failure-kingdrew
May 03, 2017 - This article reports on a death that occurred at the Martin Luther King Jr. … Copy Citation
Related Resources From the Same Author(s)
Secret data on hospital … June 11, 2014
Interactive effects of nurse-experienced time pressure and burnout on patient … safety: a cross-sectional survey. … More About The Topic
Nurses
Nurse Managers
Quality and Safety Professionals
Media
Patients
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psnet.ahrq.gov/issue/patients-teachers-randomised-controlled-trial-use-personal-stories-harm-raise-awareness
September 04, 2013 - Study
Patients as teachers: a randomised controlled trial on the use of personal … Patients as teachers: a randomised controlled trial on the use of personal stories of harm to raise awareness … Using the Attitude to Patient Safety Questionnaire , researchers found no differences in the two groups … Patients as teachers: a randomised controlled trial on the use of personal stories of harm to raise awareness … Findings from a UK multicentre survey study.
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psnet.ahrq.gov/issue/case-study-webinar-series-clinician-burnout-ohio-state-university
September 28, 2022 - 2020
Characteristics and unexpected COVID-19 diagnoses in resuscitation room patients … July 20, 2022
Alcoholism and American healthcare: the case for a patient safety approach … March 18, 2025
- March 18, 2025
Patient Safety Awareness Week. … September 7, 2022
The Good, The Bad, and The Ugly: Patient Experiences with CRPs. … June 3, 2020
Introducing the New SOPS Hospital Survey 2.0.
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psnet.ahrq.gov/issue/mortality-measure-quality-implications-palliative-and-end-life-care
June 30, 2011 - Unplanned early hospital readmission among critical care survivors: a mixed methods study of patients … Preoperative communication between anesthesia, surgery, and primary care providers for older surgical patients … March 6, 2024
Electronic health records in ambulatory care- a national survey of physicians … December 6, 2013
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Patient … Safety Innovations
Preventing Falls Through Patient and Family Engagement to Create
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psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
December 15, 2024 - Examples include patients who may be on medications that could increase their risk of falls or bleeding … , patients with indwelling central venous or urinary catheters, or patients with similar names. … The huddle leader provides updates on recent or upcoming relevant patient safety announcements and initiatives … June 14, 2023
The effect of a system-level tiered huddle system on reporting patient safety events … considerations in using personal protective equipment in the COVID-19 pandemic context: a bi-national survey
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psnet.ahrq.gov/issue/cdc-central-line-bloodstream-infection-prevention-efforts-produced-net-benefits-least-640
October 31, 2014 - Multiple national efforts focus on eliminating central line–associated bloodstream infections (CLABSIs … ), which are a key source of patient harm. … This translates into a per dollar rate of return on Centers for Disease Control and Prevention investments … August 20, 2018
Patient safety perceptions: a survey of Iowa physicians, pharmacists, … A survey of physician and nurse knowledge, attitudes, and practices around injection safety.
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psnet.ahrq.gov/issue/work-systems-analysis-approach-understanding-fatigue-hospital-nurses
July 08, 2020 - Prior research shows that nurse fatigue contributes to medical error, placing patient safety at risk … Investigators performed a secondary analysis of survey data from 340 inpatient nurses to determine how … November 3, 2015
Frontline providers' and patients' perspectives on improving diagnostic … More
Related Resources
Association of nurse engagement and nurse staffing on … patient safety.