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.

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.

… 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 …

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

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

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.

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

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

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.

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.

Warfarin therapy is frequently associated with adverse drug events. Past efforts to identify potential prevention strategies have focused on using specific indicators or triggers to detect such events. This study examined more than 9000 errors in warfarin use submitted voluntarily through MEDMARX, a database that tracks medication information from participating hospitals. Investigators discovered that inpatient warfarin-related errors occurred most frequently during transcription/documentation and administration, while outpatient errors occurred most frequently during prescribing and dispensing. Using warfarin data as an example, the authors discuss the utility of voluntary error reporting systems and outline the limitations in their use.

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

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.