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psnet.ahrq.gov/issue/social-risk-health-inequity-and-patient-safety
September 28, 2022 - Commentary
Social risk, health inequity, and patient safety.
Citation Text:
Boisvert S. Social risk, health inequity, and patient safety. J Healthc Risk Manag. 2022;42(2):18-25. doi:10.1002/jhrm.21519.
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psnet.ahrq.gov/issue/culture-cure-assessments-patient-safety-culture-oecd-countries
October 07, 2020 - Book/Report
Culture as a Cure: Assessments of Patient Safety Culture in OECD Countries.
Citation Text:
Culture as a Cure: Assessments of Patient Safety Culture in OECD Countries. de Bienassisi K, Kristensenii S, Burtscheri M, et al for the Organisation for Economic Co-operation and …
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psnet.ahrq.gov/issue/adverse-events-hospitals-quarter-medicare-patients-experienced-harm-october-2018
February 01, 2023 - Book/Report
Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018.
Citation Text:
Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018. Grimm CA. Washington DC: Office of the Inspector General; May 2022. Repor…
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psnet.ahrq.gov/perspective/implementing-fall-prevention-program
November 29, 2023 - achieving zero falls is not a reasonable aim, because it would lead to other negative consequences in terms
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psnet.ahrq.gov/submit-your-toolkit-landing
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Improvement Resources
Toolkits
Toolkit Submissions
PSNet encourages healthcare-related organizations to help make care safer by submitting a Patient Safety Toolkit to support the implementation of products, services, processes, systems, policies, organizational stru…
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psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
April 24, 2024 - If we fix the systems that impact the people that deliver care, many things may fall in place in terms
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psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
April 24, 2024 - If we fix the systems that impact the people that deliver care, many things may fall in place in terms
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psnet.ahrq.gov/perspective/ems-patient-safety-field
July 28, 2021 - KH: Can you speak to where the EMS field currently stands in terms of how it approaches patient safety … Where should we be putting our energy, whether it’s in terms of research, exploration, is it technology
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psnet.ahrq.gov/issue/preventing-parallel-pandemic-national-strategy-protect-clinicians-well-being
January 23, 2019 - Commentary
Classic
Preventing a parallel pandemic - a national strategy to protect clinicians' well-being.
Citation Text:
Dzau VJ, Kirch D, Nasca TJ. Preventing a parallel pandemic - a national strategy to protect clinicians' well-being. N Engl J Med. 2020;383(6…
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psnet.ahrq.gov/issue/spectrum-hospitalization-associated-harm-elderly
April 06, 2022 - Commentary
The spectrum of hospitalization-associated harm in the elderly.
Citation Text:
Schattner A. The spectrum of hospitalization-associated harm in the elderly. Eur J Intern Med. 2023;115(Sept):29-33. doi:10.1016/j.ejim.2023.05.025.
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psnet.ahrq.gov/issue/implementation-parent-centered-approach-preinduction-checklist-pediatric-surgery
October 05, 2022 - Study
Implementation of a parent-centered approach to the preinduction checklist in pediatric surgery.
Citation Text:
Arshad SA, Ferguson DM, Garcia EI, et al. Implementation of a Parent-centered Approach to the Preinduction Checklist in Pediatric Surgery. J Surg Res. 2021;257:455-461. d…
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psnet.ahrq.gov/issue/foundational-science-learning-health-systems
June 26, 2019 - Commentary
The foundational science of learning health systems.
Citation Text:
Kilbourne AM, Borsky AE, O'Brien RW, et al. The foundational science of learning health systems. Health Serv Res. 2024;59(6):e14374. doi:10.1111/1475-6773.14374.
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psnet.ahrq.gov/issue/value-assessment-deprescribing-interventions-suggestions-improvement
August 04, 2021 - Commentary
Value assessment of deprescribing interventions: suggestions for improvement.
Citation Text:
Hung A, Wang J, Moriarty F, et al. Value assessment of deprescribing interventions: suggestions for improvement. J Am Geriatr Soc. 2023;71(6):2023-2027. doi:10.1111/jgs.18298.
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psnet.ahrq.gov/issue/patient-safety-and-ethical-implications-healthcare-sick-leave-policies-pandemic-era
September 16, 2020 - Commentary
Patient safety and ethical implications of healthcare sick leave policies in the pandemic era.
Citation Text:
Preston-Suni K, Celedon MA, Cordasco KM. Patient safety and ethical implications of healthcare sick leave policies in the pandemic era. Jt Comm J Qual Patient Saf. 202…
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psnet.ahrq.gov/issue/organisational-conditions-safety-management-practice-homecare-and-nursing-homes-pre-pandemic
August 03, 2022 - Study
Organisational conditions for safety management practice in homecare and nursing homes, pre-pandemic and in pandemic.
Citation Text:
Dellve L, Skagert K. Organisational conditions for safety management practice in homecare and nursing homes, pre-pandemic and in pandemic. Safety Sci…
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psnet.ahrq.gov/issue/learning-health-system-agenda-organizational-approaches-enhancing-occupational-well-being
October 28, 2020 - Commentary
A learning health system agenda for organizational approaches to enhancing occupational well-being among clinicians.
Citation Text:
Rotenstein LS, Melnick ER, Sinsky CA. A learning health system agenda for organizational approaches to enhancing occupational well-being among cl…
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psnet.ahrq.gov/issue/barriers-incident-reporting-among-nurses-qualitative-systematic-review
September 21, 2022 - Review
Emerging Classic
Barriers to incident reporting among nurses: a qualitative systematic review.
Citation Text:
Hamed MMM, Konstantinidis S. Barriers to incident reporting among nurses: a qualitative systematic review. West J Nurs Res. 2022;44(5):506-523. d…
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psnet.ahrq.gov/issue/framework-analysis-communication-errors-health-care
October 21, 2020 - Commentary
A framework for the analysis of communication errors in health care.
Citation Text:
Bender JA, Thiyagarajan S, Morrish W, et al. A framework for the analysis of communication errors in health care. J Patient Saf. 2025;21(2):69-81. doi:10.1097/pts.0000000000001303.
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - SPOTLIGHT CASE
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
Citation Text:
Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research…
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psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
October 01, 2009 - through any of these avenues, what is the usual response and what advice would you give hospitals in terms … Times does a really good job, in terms of analyzing patient records and state regulatory reports.