The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 20 of 28 Results

From HRO to HERO: making health equity a core system capability.

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Moy E, Hausmann LRM, Clancy CM. Am J Med Qual. 2022;37:81-83.

Shortcomings in health equity represent systemic weaknesses in health care. This commentary suggests that actions to reduce disparities be added to the components of high reliability organizations (HRO) to facilitate an expansion of the HRO concept to address the threat to patient safety that inequity represents.

Developing a systematic approach to safer medication use during pregnancy: summary of a Centers for Disease Control and Prevention–convened meeting.

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Broussard CS, Frey MT, Hernandez-Diaz S, et al. Am J Obstet Gynecol. 2014;211:208-214.e1.

… Obstet Gynecol … This commentary summarizes findings from a multidisciplinary panel, convened as part of a broad-based obstetric medication safety improvement … of providing guidance on these processes and developing a systematic approach for other teams initiating similar …

Alleviating "second victim" syndrome: how we should handle patient harm.

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Clancy CM. J Nurs Care Qual. 2012;27:1-5.

This commentary discusses second victims and describes how blame-free reporting and disclosure can minimize harm.

New research highlights the role of patient safety culture and safer care.

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Clancy CM. J Nurs Care Qual. 2011;26:193-6.

This commentary explores how implementing safety culture interventions hospital-wide can improve patient safety.

The science of safety improvement: learning while doing.

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Clancy CM, Berwick DM. Ann Intern Med. 2011;154:699-701.

… Annals of internal medicine … Ann Intern Med … Accompanying a consensus statement , this editorial discusses the …

Common formats allow uniform collection and reporting of patient safety data by patient safety organizations.

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Clancy CM. American Journal of Medical Quality. 2009;25.

This article defines common formats and explains their role in the patient safety organization initiative.

Complexity, bullying, and stress: analyzing and mitigating a challenging work environment for nurses.

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Hughes RG, Clancy CM. J Nurs Care Qual. 2009;24:180-183.

The authors examine workplace factors that hinder nurses from providing safe and high-quality care.

Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and boost patient satisfaction.

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Clancy CM. Am J Med Qual. 2009;24:344-6.

… … Am J Med Qual … In this commentary, AHRQ Director Carolyn Clancy discusses effective patient discharge as an important …

Reducing health care hazards: lessons from the Commercial Aviation Safety Team.

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Pronovost P, Goeschel CA, Olsen KL, et al. Health Aff (Millwood). 2009;28:w479-89.

… safety has frequently relied on the aviation industry as a source of learning to prevent accidents and harm in health … the success of the Commercial Aviation Safety Team (CAST), a public–private enterprise voluntarily established by the … and the government in the mid-1990s. The authors, led by a pioneer in the patient safety field, propose a similar …

CMS's hospital-acquired condition lists link hospital payment, patient safety.

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Clancy CM. Am J Med Qual. 2009;24:166-8.

This commentary describes the Centers for Medicare and Medicaid Services (CMS) nonpayment policy for never events and explores its potential impact on health care.

Transformation of health care at the front line.

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Conway PH, Clancy CM. JAMA. 2009;301:763-5.

This commentary emphasizes five key drivers to improve health care delivery and suggests next steps to accomplish such changes.

Patient safety organizations ready for action.

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Clancy CM. AORN J. 2009;89:385-7.

This commentary discusses the AHRQ rule defining the role of patient safety organizations (PSOs) in safety improvement and elaborates on enhanced data protection for reporting.

Nurses' role in patient safety.

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Hughes RG, Clancy CM. J Nurs Care Qual. 2009;24:1-4.

This commentary discusses the broad role of nursing in patient safety, the leadership and organizational roles they can play, and Agency for Healthcare Research and Quality’s Evidence-Based Handbook for Nurses.

The importance of simulation: preventing hand-off mistakes.

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Clancy CM. AORN J. 2008;88:625-627.

This article discusses an AHRQ-funded communication survey initiative that utilized simulation to build effective teamwork techniques.

New patient safety organizations lower roadblocks to medical error reporting.

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Clancy CM. Am J Med Qual. 2008;23:318-21.

This article explains how AHRQ's Patient Safety Organization (PSO) initiative will help dismantle barriers to sharing data on errors.

Limiting nurse overtime, and promoting other good working conditions, influences patient safety.

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Sharp BAC, Clancy CM. J Nurs Care Qual. 2008;23:97-100.

This AHRQ commentary describes research findings linking nurses' working environment (including organizational climate, staffing, overtime, and fatigue) to patient outcomes.

How useful are voluntary medication error reports? The case of warfarin-related medication errors.

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Zhan C, Smith SR, Keyes MA, et al. Jt Comm J Qual Patient Saf. 2008;34:36-45.

… in warfarin use submitted voluntarily through MEDMARX , a database that tracks medication information from …

Patient safety in nursing practice.

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Farquhar M, Sharp BAC, Clancy CM. AORN J. 2007;86:455-7.

The authors discuss Agency for Healthcare Research and Quality (AHRQ) research regarding patient safety and nursing care.

TeamSTEPPS: assuring optimal teamwork in clinical settings.

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Clancy CM, Tornberg DN. Am J Med Qual. 2007;22:214-7.

The authors discuss the TeamSTEPPS training program—a collaboration of the US Department of Defense and Agency for Healthcare Research and Quality to enhance patient safety through improved teamwork.

Care transitions: a threat and an opportunity for patient safety.

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Clancy CM. American Journal of Medical Quality. 2006;21.

The author discusses the use of team training strategies to reduce error during patient care handoffs.

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