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psnet.ahrq.gov/issue/two-steps-forward-and-one-step-back-patient-safety
June 10, 2018 - Newspaper/Magazine Article
Two steps forward and one step back for patient safety?
Citation Text:
Two steps forward and one step back for patient safety? ISMP Medication Safety Alert! Acute Care Edition. June 30, 2005;10.
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psnet.ahrq.gov/issue/thirty-safe-practices-better-health-care
December 24, 2008 - Government Resource
Thirty Safe Practices for Better Health Care.
Citation Text:
Thirty Safe Practices for Better Health Care. AHRQ; Agency for Healthcare Research and Quality; NQF; National Quality Forum
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psnet.ahrq.gov/issue/patient-safety-and-adverse-maternal-health-outcomes-missing-social-inequalities-lens
August 01, 2018 - Commentary
Patient safety and adverse maternal health outcomes: the missing social inequalities 'lens.'
Citation Text:
Patient safety and adverse maternal health outcomes: the missing social inequalities 'lens.' Murray SF, Bacchus L. BJOG. 2005 Oct;112(10):1339-1343.
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psnet.ahrq.gov/issue/doctors-use-more-devices-potential-distraction-grows
March 06, 2005 - Newspaper/Magazine Article
As doctors use more devices, potential for distraction grows.
Citation Text:
As doctors use more devices, potential for distraction grows. Richtel M.
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psnet.ahrq.gov/issue/transforming-hospitals-designing-safety-and-quality
May 01, 2015 - Audiovisual
Transforming Hospitals: Designing for Safety and Quality.
Citation Text:
Transforming Hospitals: Designing for Safety and Quality. Rockville, MD: Agency for Healthcare Research and Quality; December 2014.
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psnet.ahrq.gov/issue/man-made-disasters-2nd-ed
January 01, 2012 - Book/Report
Classic
Man-Made Disasters. 2nd ed.
Citation Text:
Man-Made Disasters. 2nd ed. Turner BA, Pidgeon NF. Oxford, UK: Butterworth-Heinemann; 1997.
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psnet.ahrq.gov/issue/ambulatory-surgery-facilities-comprehensive-review-medication-error-reports-pennsylvania
April 17, 2017 - Newspaper/Magazine Article
Ambulatory surgery facilities: a comprehensive review of medication error reports in Pennsylvania.
Citation Text:
Ambulatory surgery facilities: a comprehensive review of medication error reports in Pennsylvania.
Grissinger M, Dabliz R. Pa Patient S…
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psnet.ahrq.gov/issue/surgical-checklists-unused-10-hospitals-cms-data-shows
October 01, 2014 - Newspaper/Magazine Article
Surgical checklists unused in 10% of hospitals, CMS data shows.
Citation Text:
Surgical checklists unused in 10% of hospitals, CMS data shows. Clark C. HealthLeaders Media. July 24, 2014.
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psnet.ahrq.gov/issue/apsf-20-year-anniversary-first-patient-safety-organization-past-present-future
October 26, 2022 - Newspaper/Magazine Article
The APSF: 20-year anniversary of the first patient safety organization: past, present & future.
Citation Text:
The APSF: 20-year anniversary of the first patient safety organization: past, present & future. Cooper JB. APSF Newsletter. 2007;22(1):1,3.
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psnet.ahrq.gov/issue/medical-errors-affecting-pediatric-intensive-care-patient-incidence-identification-and
June 26, 2019 - Review
Medical errors affecting the pediatric intensive care patient: incidence, identification, and practical solutions.
Citation Text:
Medical errors affecting the pediatric intensive care patient: incidence, identification, and practical solutions. Nichter MA.
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psnet.ahrq.gov/issue/dangerous-connections-health-care-community-tackles-tubing-risks-small-bore-connector
October 26, 2007 - Newspaper/Magazine Article
Dangerous connections: health care community tackles tubing risks, small-bore connector standards.
Citation Text:
Dangerous connections: health care community tackles tubing risks, small-bore connector standards. Vockley M. Joint Commission: The Source. Jun…
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psnet.ahrq.gov/issue/heed-warning-dont-miss-important-computer-alerts
May 07, 2018 - Newspaper/Magazine Article
Heed this warning! Don't miss important computer alerts.
Citation Text:
Heed this warning! Don't miss important computer alerts. ISMP Medication Safety Alert! Acute Care Edition. February 8, 2007;12:1-2.
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/randeree-e-et-al-2007
January 01, 2007 - Randeree E et al. 2007 "Exploring physician adoption of EMRs: a multi-case analysis."
Reference
Randeree E. Exploring physician adoption of EMRs: a multi-case analysis. J Med Syst 2007;31(6):489-496.
Abstract
"The adoption of new technology within healthcare has been promoted as a way to reduc…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/kruger-df-et-al-2003
January 01, 2003 - Kruger DF et al. 2003 "Effect of modem transmission of blood glucose data on telephone consultation time, clinic work flow, and patient satisfaction for patients with gestational diabetes mellitus."
Reference
Kruger DF, White K, Galpern A, et al. Effect of modem transmission of blood glucose data on t…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/unertl-km
January 01, 2023 - Unertl KM, Weinger MB, Johnson KB, et al. "Describing and modeling workflow and information flow in chronic disease care."
Reference
Unertl KM, Weinger MB, Johnson KB, et al. Describing and modeling workflow and information flow in chronic disease care. J Am Med Inform Assoc 2009 Nov-Dec;16(6):826-36.…
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psnet.ahrq.gov/issue/can-computers-help-doctors-reduce-diagnostic-errors
December 18, 2019 - Newspaper/Magazine Article
Can computers help doctors reduce diagnostic errors?
Citation Text:
Can computers help doctors reduce diagnostic errors? Shryock T. Med Econ. December 5, 2016.
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psnet.ahrq.gov/issue/making-hospitals-safe-people-diabetes
November 14, 2018 - Book/Report
Making Hospitals Safe for People With Diabetes.
Citation Text:
Making Hospitals Safe for People With Diabetes. Watts E, Rayman G. Diabetes UK. London, UK; 2018.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.359_slideshow.ppt
October 01, 2015 - PowerPoint Presentation
Spotlight
The Risks of Absent Interoperability:
Medication-Induced Hemolysis in a Patient With a Known Allergy
1
This presentation is based on the October 2015
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/
CME credit is available
Commentary by: Jacob Reider,…
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psnet.ahrq.gov/node/33684/psn-pdf
May 01, 2009 - Patient Safety: A Perspective from Office Practice
May 1, 2009
Baron RJ. Patient Safety: A Perspective from Office Practice. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
Perspective
Most patient interactions with the health care system occur in the outpatien…
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www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/guide-staffing-during-COVID19.pdf
June 02, 2025 - Staffing During the COVID-19 Pandemic: A Guide for Nursing Home Leaders
Staffing During the COVID-19 Pandemic:
A Guide for Nursing Home Leaders
Introduction
This resource guide was written by and for directors of nursing, administrators, and other nursing home
leaders. It outlines steps to reduce or elimi…