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psnet.ahrq.gov/node/33574/psn-pdf
March 15, 2025 - Poorly handled care transitions (e.g., when a patient is discharged from the hospital or
when care is
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psnet.ahrq.gov/primer/culture-safety
September 15, 2024 - April 10, 2024
Patient Safety Primers
Inpatient Transitions
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - used appropriately, can help standardize and organize the most crucial aspects of care during these transitions … Medication
September 30, 2020
WebM&M Cases
Lost in Transitions
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psnet.ahrq.gov/node/49852/psn-pdf
February 01, 2019 - As we know from other hospital-based care transitions, including patient discharge and intrahospital … patient
handoffs, high-quality communication and information exchange during care transitions are essential
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psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
September 01, 2017 - most of us who have been at that ground level think that there probably is underreporting—that those transitions … identified some areas where that was the case, but they particularly suggested that it's risky during these transitions … June 24, 2020
Applying requisite imagination to safeguard electronic health record transitions
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psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
January 01, 2020 - Improving Patient Handoffs and Transitions through Adaptation and Implementation of I-PASS
Across Multiple
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psnet.ahrq.gov/web-mm/communication-failure-whos-charge
April 01, 2018 - Specific focus on perioperative transitions of care for children with congenital heart disease is more
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psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
February 21, 2024 - Care home safety incidents and safeguarding reports relating to hospital to care home transitions
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psnet.ahrq.gov/issue/ismp-medication-safety-alertr-nurse-advise-err
January 26, 2023 - Newsletter/Journal
ISMP Medication Safety Alert!® Nurse-Advise ERR.
Citation Text:
ISMP Medication Safety Alert!® Nurse-Advise ERR. Plymouth Meeting, PA: Institute for Safe Medication Practices.
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psnet.ahrq.gov/issue/how-make-emergency-department-visit-safe-one
November 02, 2005 - Government Resource
How to Make an Emergency Department Visit a Safe One.
Citation Text:
How to Make an Emergency Department Visit a Safe One. Clancy CM.
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psnet.ahrq.gov/issue/hospitals-save-money-safety-questioned
January 18, 2006 - Newspaper/Magazine Article
Hospitals save money, but safety is questioned.
Citation Text:
Hospitals save money, but safety is questioned. Klein A. Washington Post. December 11, 2005.
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psnet.ahrq.gov/issue/human-factors-and-ergonomics-patient-safety
June 21, 2006 - Special or Theme Issue
Human Factors and Ergonomics in Patient Safety.
Citation Text:
Human Factors and Ergonomics in Patient Safety. Carayon P, Buckle P, eds. App Ergon. 2010:41(5):643-718.
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psnet.ahrq.gov/issue/jcaho-launch-global-patient-safety-center-initial-focus-will-be-reviewing-and-publicizing
December 22, 2010 - Newspaper/Magazine Article
JCAHO to launch global patient safety center: the initial focus will be on reviewing and publicizing research findings.
Citation Text:
JCAHO to launch global patient safety center: the initial focus will be on reviewing and publicizing research findings. Robezn…
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psnet.ahrq.gov/issue/dont-come-back-hospitals-say
August 17, 2016 - Newspaper/Magazine Article
Don't come back, hospitals say.
Citation Text:
Don't come back, hospitals say. Landro L.
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psnet.ahrq.gov/issue/making-hospitals-accountable
December 09, 2020 - Newspaper/Magazine Article
Making hospitals accountable.
Citation Text:
Making hospitals accountable. Peters PG Jr.
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psnet.ahrq.gov/issue/special-issue-health-information-technology
August 22, 2007 - Special or Theme Issue
Special Issue on Health Information Technology.
Citation Text:
Special Issue on Health Information Technology. J Gen Intern Med. 2008;23:353-507.
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psnet.ahrq.gov/issue/nursing-care-quality-nqf
September 06, 2011 - Multi-use Website
Nursing Care Quality at NQF.
Citation Text:
Nursing Care Quality at NQF. National Quality Forum
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psnet.ahrq.gov/issue/minnesota-hospitals-are-testing-ways-reduce-return-trips
January 18, 2012 - Newspaper/Magazine Article
Minnesota hospitals are testing ways to reduce return trips.
Citation Text:
Minnesota hospitals are testing ways to reduce return trips. Lerner M. Lerner M. Star Tribune. October 11, 2012.
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psnet.ahrq.gov/issue/safety-you-go-hospital-home
November 23, 2016 - Fact Sheet/FAQs
Safety as You Go from Hospital to Home.
Citation Text:
Safety as You Go from Hospital to Home. National Patient Safety Foundation; NPSF
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psnet.ahrq.gov/issue/getting-medicines-right
January 26, 2022 - Toolkit
Getting the Medicines Right.
Citation Text:
Getting the Medicines Right. The Royal Pharmaceutical Society.
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