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psnet.ahrq.gov/issue/slow-troubling-death-autopsy
August 19, 2020 - author ties the relevance of the loss to missed opportunities for understanding the effect of COVID-19 on … Intraoperative sentinel events in the era of surgical safety checklists: results of a national survey … March 3, 2021
The Collective Leadership for Safety Culture (Co-Lead) team intervention … to promote teamwork and patient safety. … 'There is a real cost’: as Covid shows, barring bedside visitors from ICU deprives patients
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psnet.ahrq.gov/issue/patient-safety-when-receiving-telephone-advice-primary-care-swedish-qualitative-interview
October 13, 2021 - Study
Patient safety when receiving telephone advice in primary care - a Swedish … Interviews with nurses resulted in an overall theme of “being able to make the right decision ” based on … September 14, 2022
Patient safety skills in primary care: a national survey of GP educators … September 14, 2022
Fidelity and the impact of patient safety huddles on teamwork and … safety culture: an evaluation of the Huddle Up for Safer Healthcare (HUSH) project.
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psnet.ahrq.gov/issue/mentorship-newly-appointed-physicians-strategy-enhancing-patient-safety
April 22, 2012 - enhanced emotional well-being, and promoted organizational commitment which can contribute to a stronger safety … culture . … December 21, 2016
Improving patient safety through the involvement of patients: development … and evaluation of novel interventions to engage patients in preventing patient safety incidents and … : an online survey study.
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psnet.ahrq.gov/issue/improving-safety-intravenous-admixtures-lessons-learned-pentostamr-overdose
January 04, 2017 - Jt Comm J Qual Patient Saf. 2006;32(7):366-72. … Jt Comm J Qual Patient Saf . 2006; 32 (7) :366-72 . … Jt Comm J Qual Patient Saf. 2006;32(7):366-72. … device-associated infections during the coronavirus disease 2019 (COVID-19) pandemic: results from a national survey … Safety
January 31, 2024
Recommendations from a national panel on quality improvement
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psnet.ahrq.gov/node/47111/psn-pdf
September 26, 2018 - Inter- and intra-disciplinary collaboration and patient
safety outcomes in U.S. acute care hospital … Inter- and intra-disciplinary collaboration and patient safety outcomes in U.S. … -
acute-care-hospital
Teamwork training interventions enhance both clinical outcomes and safety culture … This cross-sectional
survey found hospital units that nurses rated as more collaborative had lower rates … A PSNet Interview discusses how the nursing work environment affects
patient safety.
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psnet.ahrq.gov/issue/getting-underuse-interpreters-resident-physicians
February 21, 2018 - Resident physicians reported relying on family interpreters or their own second language skills when … caring for non–English-speaking patients, even though the physicians acknowledged that use of professional … interpreters could benefit patient care. … survey of practices and recommendations. … May 5, 2010
What are covering doctors told about their patients?
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psnet.ahrq.gov/issue/health-care-professionals-second-victims-after-adverse-events-systematic-review
September 19, 2016 - Focusing on health care providers as the second victims of adverse events, this review explores the … September 27, 2016
How different countries respond to adverse events whilst patients' … and Workforce Safety Culture in Healthcare
March 27, 2024
Support for healthcare … workers and patients after medical error through mutual healing: another step towards patient safety … January 18, 2023
Multispecialty physician online survey reveals that burnout related
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psnet.ahrq.gov/issue/beyond-service-quality-mediating-role-patient-safety-perceptions-patient-experience
January 14, 2011 - However, this survey of hospitalized patients found that both perceptions of safety and service quality … October 4, 2011
Acute care patients discuss the patient role in patient safety. … December 3, 2014
The impact of health system membership on patient safety initiatives … November 28, 2016
Family-centered rounds on pediatric wards: a PRIS network survey of … November 23, 2016
Hospitalized patients' participation and its impact on quality of care
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psnet.ahrq.gov/issue/characterising-near-miss-events-complex-laparoscopic-surgery-through-video-analysis
October 09, 2013 - September 25, 2019
Healthcare professionals' perception of safety culture and the Operating … Room (OR) Black Box technology before clinical implementation: a cross-sectional survey. … August 25, 2021
Impact of team performance on the surgical safety checklist on patient … October 4, 2023
View More
Related Resources
Patient … morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients
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psnet.ahrq.gov/issue/oncology-nurses-beliefs-and-attitudes-towards-double-check-chemotherapy-medications-cross
September 07, 2016 - April 1, 2020
Patient safety threats in information management using health information … August 8, 2018
The impact of type of manual medication cart filling method on the frequency … January 23, 2019
Effect of warning symbols in combination with education on the frequency … August 8, 2010
Potential for drug interactions in hospitalized cancer patients. … April 27, 2010
Oncology nurses' perceptions about involving patients in the prevention
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www.ahrq.gov/patient-safety/resources/learning-lab/yale-center-long-desc.html
June 01, 2020 - outcomes of transfers. 1-3 To support this work, it developed the following products:
Multiple survey … Real-time surveys reveal important safety risks during interhospital care transitions for neurologic … Real-time surveys reveal important safety risks during interhospital care transitions for neurologic … Clinician perspectives on goals of care for patients discharged from hospitals to skilled nursing facilities … Perspectives of clinicians at skilled nursing facilities on 30-day hospital readmissions: a qualitative
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2021qdr-intro-methods.pdf
December 01, 2021 - and patient safety culture. … Some survey designs, questionnaires, data collection methods, definitions, and data
calculation methods … Data Base (NCDB)
United States Census Bureau
• American Community Survey (ACS)
Populations
Overall … Disabilities: Disability status is defined based on the methodology of the American
Community Survey … Limitations With the Medicare Patient Safety Monitoring System Data
For these measures, “hospital patients
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psnet.ahrq.gov/issue/diagnosing-fast-and-slow-cognitive-bias-obstetrics
February 22, 2019 - December 18, 2024
Global drug shortages due to COVID-19: impact on patient care and mitigation … July 8, 2020
Effect of patient safety education interventions on patient safety culture … Workplace violence pervasiveness in the perioperative environment: a multiprofessional survey … November 13, 2024
Impact of patient safety bundle and team-based training on obstetric … September 4, 2024
Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis
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psnet.ahrq.gov/issue/incidence-and-nature-adverse-events-during-pediatric-sedationanesthesia-propofol-procedures
April 11, 2011 - on pediatric patient safety in the emergency department. … safety culture in a tertiary maternity unit. … maximizing training while sensing patient safety threats. … June 9, 2011
A survey of the impact of disruptive behaviors and communication defects … on patient safety.
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psnet.ahrq.gov/issue/nurse-managers-leadership-patient-safety-and-quality-care-systematic-review
September 09, 2020 - This review identified 14 studies of the impact of nurse leadership on adverse patient outcomes, rates … Resources From the Same Author(s)
The enabling, enacting, and elaborating factors of safety … culture associated with patient safety: a multilevel analysis. … of ADEs after discharge from hospital in patients with polypharmacy. … Risk of medication errors and nurses' quality of sleep: a national cross-sectional web survey
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psnet.ahrq.gov/issue/nurses-perspectives-intersection-safety-and-informed-decision-making-maternity-care
May 21, 2019 - May 21, 2019
Effective physician–nurse communication: a patient safety essential for … September 23, 2020
Transforming communication and safety culture in intrapartum care: … August 27, 2012
The effects of on-duty napping on intern sleep time and fatigue. … victim experiences of nurses in obstetrics and gynaecology: a Second Victim Experience and Support Tool Survey … June 11, 2019
The effect of collaboration on obstetric patient safety in three academic
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/implementing-cms-measure-slides.pdf
May 13, 2025 - Hatlie, JD
Patients for Patient
Safety U.S. … 4
Questions to Run On
• What is the Patient Safety Structural Measure? … Hatlie, JD
Co-founder and Director For Policy & Advocacy, Patients For Patient Safety US
The Patient … accountability
Culture of Safety and
Learning Systems
Hospital conducts hospital-
wide culture of safety survey … on safety-related activities
Patients have comprehensive
access to medical records via
patient portals
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psnet.ahrq.gov/issue/evaluating-impact-radio-frequency-identification-retained-surgical-instruments-tracking
August 03, 2022 - Evaluating the impact of radio frequency identification retained surgical instruments tracking on patient … August 3, 2022
Providers' and patients' perspectives on diagnostic errors in the acute … May 4, 2022
Impact of teamwork and communication training interventions on safety culture … errors in acutely ill patient presentation: a survey of academic and community practice. … Meta-analyses on provider, patient, organisational, and handoff outcomes.
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psnet.ahrq.gov/issue/medical-errors-recovered-critical-care-nurses
June 04, 2008 - This survey of critical care nurses revealed that nurses witness and are involved in preventing a wide … June 28, 2010
Optimizing Pediatric Patient Safety in the Emergency Care Setting. … October 19, 2022
Lessons learned implementing a complex and innovative patient safety … June 2, 2019
View More
Related Resources
Impact of alarm fatigue on … October 26, 2011
Structural empowerment and patient safety culture among registered nurses
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psnet.ahrq.gov/issue/harmful-errors-how-will-your-facility-respond
November 05, 2014 - November 2, 2022
Survey results from pharmacists provide support to enhance the organizational … April 29, 2018
IV vincristine survey shows safety improvements needed. … April 29, 2018
Practitioners agree on medication reconciliation value, but frustration … April 29, 2018
Rapid response team activation by patients can mitigate errors. … April 17, 2019
The "Seven Pillars" response to patient safety incidents: effects on medical