Unmet health-related social needs (HRSNs; e.g., housing instability, food insecurity) and healthcare disparities can place patients at increased risk for patient safety incidents and poor outcomes. This article describes how existing Veterans Health Administration (VHA) initiatives to address HRSNs and disparities are being leveraged to address new Joint Commission standards to improve health care equity.

Health inequities among people of color are the result of multiple systemic and clinician factors. This study shows Black and Hispanic/Latino patients who experience racism in healthcare, report worse views on the quality of their care and lower trust in their clinicians. These findings suggest that eliminating racism at the organization and clinician level may improve quality of care for patients of color.

… Am J Med Qual … Shortcomings in health equity represent systemic … threat to patient safety that inequity represents. … Moy E, Hausmann LRM, Clancy CM. From HRO to HERO: making health equity a core …

This study explored views, practices, and needs related to patient counseling on medication safety in obstetrics and gynecology. Survey responses from over 500 OB/GYNs indicate opportunities to improve available resources and information sharing, such as developing new tools to communicate about teratogenic medications and pregnancy-safe over-the-counter medications and dietary supplements.

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

… Journal of nursing care quality … J Nurs Care Qual … This commentary explores how implementing …

Accompanying a consensus statement, this editorial discusses the challenges of conducting research in complex settings, and notes existing guidelines and resources to help clinicians write and interpret articles about patient safety interventions.

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

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

In this commentary, AHRQ Director Carolyn Clancy discusses effective patient discharge as an important factor in patient safety. Specifically, she highlights elements of an AHRQ-funded implementation program for engaging patients along with their clinical team to enable smooth discharge.

Since the landmark IOM report on medical errors, the field of patient safety has frequently relied on the aviation industry as a source of learning to prevent accidents and harm in health care. This commentary explores these learnings further by highlighting the success of the Commercial Aviation Safety Team (CAST), a public–private enterprise voluntarily established by the aviation industry and the government in the mid-1990s. The authors, led by a pioneer in the patient safety field, propose a similar partnership in the health care community to coordinate a national agenda in improving the quality and safety of care. They call the proposed organization the Public Private Partnership to Promote Patient Safety (P5S), and provide a model for its success.

… journal of the American College of Medical Quality … Am J Med Qual … This commentary describes the Centers for …

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

… AORN journal … AORN J … This commentary discusses the AHRQ rule defining the role …

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.

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

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

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

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … Warfarin therapy is frequently …

… AORN journal … AORN J … The authors discuss Agency for Healthcare Research and …