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psnet.ahrq.gov/issue/smart-pump-custom-concentrations-without-hard-low-concentration-alerts
June 10, 2018 - June 10, 2018
Results of ISMP survey on high-alert medications: differences between nursing … February 13, 2019
Prescription drug time guarantees and their impact on patient safety … June 10, 2018
Results of our survey on drug storage, stability, compatibility, and beyond … October 31, 2012
IV vincristine survey shows safety improvements needed. … December 30, 2014
Missed medication doses in hospitalised patients: a descriptive account
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psnet.ahrq.gov/issue/six-steps-head-hand-simulator-based-transfer-oriented-psychological-training-improve-patient
August 20, 2018 - Six steps from head to hand: a simulator based transfer oriented psychological training to improve patient … Characteristics of critical incident reporting systems in primary care: an international survey … September 24, 2016
View More
Related Resources
Patient safety culture … : effects on behaviour and attitude. … January 18, 2011
Symposium on Simulation Science in Health and Medicine.
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psnet.ahrq.gov/issue/questionable-hospital-chart-documentation-practices-physicians
August 10, 2011 - documentation practices, such as recording information that they did not personally obtain or writing notes on … patients not seen or examined. … modeling of documentation behaviors, and the greater impact of billing and medical-legal influences on … November 12, 2014
Burnout in pediatric residents: three years of national survey … September 27, 2016
Hospitalized patients' understanding of their plan of care.
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-particpant-workbook.pdf
February 04, 2022 - Patient Satisfaction Surveys, Complaints
Employee Satisfaction, Culture Surveys
X
X
X
X
X
X … The survey should be
administered anonymously and can be done via paper-based or electronic administration … tool, debriefing events, safety culture surveys). … in the Diagnostic Process
On the following page is the “Be the Expert on You” patient note sheet (English … Put the Patient First: Understand patients’ values and preferences.
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psnet.ahrq.gov/issue/common-predictors-nurse-reported-quality-care-and-patient-safety
March 20, 2019 - Researchers analyzed survey data from 731 nurses to understand predictors of nurse-reported quality of … January 5, 2017
Prevalence and predictors of adverse events in older surgical patients … : impact of the present on admission indicator. … March 3, 2011
Effects of the I-PASS nursing handoff bundle on communication quality and … December 22, 2018
View More
Related Resources
Patient safety culture
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psnet.ahrq.gov/issue/survey-shows-room-improvement-two-new-ismp-targeted-medication-safety-best-practices
February 12, 2020 - Newspaper/Magazine Article
Survey shows room for improvement with two new ISMP Targeted … Citation Text:
Survey shows room for improvement with two new ISMP Targeted Medication Safety Best … This article reports on the results of a survey on the use of practices to improve the safety of prescribing … Latent and active failures perfectly align to allow a preventable adverse event to reach a patient … November 17, 2021
Leaving a discontinued FentaNYL infusion attached to the patient leads
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psnet.ahrq.gov/issue/2013-annual-hospital-acquired-condition-rate-and-estimates-cost-savings-and-deaths-averted
May 01, 2017 - The analysis indicated that hospitalized patients experienced 1.3 million fewer HACs over the 3 years … improvements coincided with nationwide efforts to reduce adverse events, such as the Partnership for Patients … September 16, 2015
Medical Office Survey on Patient Safety Culture: 2016 User Comparative … May 18, 2022
National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015 … : Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths
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psnet.ahrq.gov/issue/how-major-public-hospital-protecting-doctors-silencing-patients-who-accuse-them
January 24, 2024 - Citation Text:
How a major public hospital is protecting doctors by silencing the patients who accuse … Transparency is a primary element of an organizational safety culture that enables recognition of medical … error to inform improvement and responsible redress for the patient and family. … May 27, 2020
Survey by Ohio regulator shows stress, fatigue among pharmacists at chain … safety risks to reporting patient complaints: a grounded theory study on patients' hospital experiences
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psnet.ahrq.gov/issue/nurse-staffing-and-medication-errors-cross-sectional-or-longitudinal-relationships
February 15, 2011 - October 7, 2020
Adverse events and perceived abandonment: learning from patients' accounts … September 28, 2022
Better nurse staffing is associated with survival for Black patients … December 9, 2020
The enabling, enacting, and elaborating factors of safety culture associated … of care: A cross‐sectional survey study of medical‐surgical nurses. … February 2, 2011
Effects of learning climate and registered nurse staffing on medication
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psnet.ahrq.gov/issue/improving-medication-administration-safety-community-hospital-setting-using-lean-methodology
September 23, 2020 - September 23, 2020
Identifying safety practices perceived as low value: an exploratory survey … July 18, 2016
Medication histories in critically ill patients completed by pharmacy personnel … June 16, 2019
Recommendations from a national panel on quality improvement in obstetrics … February 1, 2012
Creating a safety culture at the Children's and Women's Health Centre … January 14, 2011
Patient Safety Papers 5.
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psnet.ahrq.gov/node/38582/psn-pdf
May 22, 2023 - https://psnet.ahrq.gov/issue/serious-reportable-events-massachusetts
This reoccurring report compiles patient … serious-reportable-events-healthcare-2011-update
https://psnet.ahrq.gov/issue/ambulatory-surgery-center-survey-patient-safety-culture
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psnet.ahrq.gov/issue/association-workflow-interruptions-and-hospital-doctors-workload-prospective-observational
March 06, 2013 - safety culture in the operating theatre: a controlled intervention study. … and nature of harm to patients in hospital. … May 30, 2011
Patient involvement in patient safety: how willing are patients to participate … December 11, 2013
Motivational antecedents of incident reporting: evidence from a survey … October 8, 2013
Distractions and their impact on patient safety.
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psnet.ahrq.gov/node/50934/psn-pdf
February 26, 2020 - psnet.ahrq.gov/issue/career-impact-chief-resident-quality-and-safety-training-program-alumni-
evaluation
A survey … program alumni suggests that
such programs can teach residents to lead and engage other residents in patient … career-impact-chief-resident-quality-and-safety-training-program-alumni-evaluation
https://psnet.ahrq.gov/issue/department-veterans-affairs-chief-resident-quality-and-patient-safety-program-model-spread
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psnet.ahrq.gov/issue/interpretability-doctor-identification-badges-uk-hospitals-survey-nurses-and-patients
October 07, 2013 - Study
The interpretability of doctor identification badges in UK hospitals: a survey … of nurses and patients. … The interpretability of doctor identification badges in UK hospitals: a survey of nurses and patients … The interpretability of doctor identification badges in UK hospitals: a survey of nurses and patients … June 22, 2017
Burnout in the NICU setting and its relation to safety culture.
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psnet.ahrq.gov/perspective/handoffs-and-transitions
February 01, 2007 - Another 2014 study focused on the specific handoff issue created by the "morning holdover"—a patient … However, the year's literature did shed light on how to best identify patients at highest risk for readmission … Building on efforts to help identify the highest risk patients during care transitions, a new study … culture. … July 2, 2014
AHRQ's Hospital Survey on Patient Safety Culture: psychometric analyses.
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psnet.ahrq.gov/node/73865/psn-pdf
September 22, 2021 - Second victims among baccalaureate nursing students in
the aftermath of a patient safety incident: an … Second victims among baccalaureate nursing students in
the aftermath of a patient safety incident: an … https://psnet.ahrq.gov/issue/second-victims-among-baccalaureate-nursing-students-aftermath-patient- … safety-incident
An online survey of nursing students in Belgium found that about one in three students … were involved in a
patient safety incident during their clinical training, and the majority experienced
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www.ahrq.gov/sites/default/files/2025-03/hinson-levin-report.pdf
January 01, 2025 - This finding informed our next project, which focused on provision of patient outcome information to … Through observations, semi-structured interviews, and
surveys, a team of designers from MICA gathered … The second phase, Technical Development, focused on the selection of patient outcomes for inclusion in … Twelve EM
physicians interacted with LOOP for a minimum of 30 minutes, followed by surveys and interviews … , highlighting a need for more balanced and accessible feedback on patient outcomes.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Donaldson_87.pdf
April 23, 2008 - Coaches worked with sites to complete self-assessment surveys and to plan subsequent steps in
sustaining … A short formative survey was sent to
CNOs midway through the project to be completed by CNOs with linker … variables 52 96
Medications patient was on
at time of fall 27 75
Equipment in use 46 82
Patient … Intervals of fall risk assessment defined as:
Q shift on all patients 40 64
Q shift on at-risk … patients 36 4
Other 24 32
Fall risk assessment tool
Internally developed with reliability and
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psnet.ahrq.gov/issue/how-avoid-paediatric-medication-errors-users-guide-literature
May 26, 2011 - Related Resources From the Same Author(s)
Effect of computer order entry on … May 27, 2011
A human factors framework and study of the effect of nursing workload on … patient safety and employee quality of working life. … View More
Related Resources
Medication errors involving pediatric patients … July 20, 2016
Medication safety in the operating room: a survey of preparation methods
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psnet.ahrq.gov/issue/nursing-homes-despite-increased-oversight-challenges-remain-ensuring-high-quality-care-and
July 12, 2006 - findings from a 5-year review of nursing home quality and safety, which revealed inconsistencies in state surveys … Related Resources From the Same Author(s)
Clinical Lab Quality: CMS and Survey … December 9, 2020
Patient Options for Safe and Effective Disposal of Unused Opioids. … by Engaging Patients and Families. … May 27, 2020
Clinical Lab Quality: CMS and Survey Organization Oversight Should Be Strengthened