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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 302 Results
Rockville, MD; Agency for Healthcare Quality and Research; March 2016.
… Book/Report … Web Resource … Patient safety culture surveys uncover insights into organizational … selective resource list offers materials for ambulatory surgery centers that seek to implement changes in response to …
Birkmeyer JD, Finks JF, O'Reilly A, et al. N Engl J Med. 2013;369(15):1434-1442.
… Study … The New England journal of medicine … N Engl J Med … Prior research has shown that … This groundbreaking study has profound implications for improving the safety of surgery. At least 10 independent surgeon-reviewers …
Perspective on Safety August 28, 2024

This piece provides an overview of Safety-II principles and discusses ways healthcare systems are integrating Safety-II principles into safety programs and care delivery.

Dr. Chalapathy Venkatesan and Kathy Helak headshot image

Dr. Chalapathy Venkatesan is the Chief Quality and Safety Officer, and Kathy Helak is the Assistant Vice President for Patient Safety at Inova Health System. We spoke to them about Safety-II principles and their application at Inova.

Organizational Policy/Guidelines
Remick K, Gausche-Hill M, Joseph MM, et al. Pediatrics. 2018;142(5):e20182459.
… Commentary … Pediatrics … Pediatrics … This revised set of guidelines suggests standards to ensure high-quality care … in the emergency department , including a section on improving patient safety . Key recommendations focus on pediatric emergency …
Ban KA, Gibbons MM, Ko CY, et al. Anesth Analg. 2019;128(5):879-889.
… Anesthesia and analgesia … Anesth Analg … Standardization of care protocols has been shown to improve perioperative outcomes . This article presents the results of an evidence review to develop best practices for perioperative care around colorectal surgery. The authors acknowledge the need for local tailoring …
Garnerin P, Arès M, Huchet A, et al. Qual Saf Health Care. 2008;17(6):454-8.
… Study … Quality & safety in health care … Qual Saf Health Care … This study combined implementation of verification protocols with periodic audits and feedback … in the prevention of wrong-patient and wrong-site surgery . While the process did improve, the authors advocate …
Haynes AB, Weiser TG, Berry WR, et al. N Engl J Med. 2009;360(5):491-9.
… Study … The New England journal of medicine … N Engl J Med … Success in patient safety is generally measured in incremental steps rather than … have already proved to be a powerful intervention in improving patient safety. This study's senior author, Atul …
Patient Safety Innovation March 29, 2023
… Study … J Patient Saf … Improving non-technical skills - such as teamwork and communication – is essential to safe delivery of healthcare but implementing successful training programs … The RAS Olympics consisted of four “events” – (1) safety hazard identification, (2) troubleshooting, (3) a …
WebM&M Case April 24, 2024
… Disclosure of Relevant Financial Relationships: As a provider accredited … cardioversion. Describe the reasons for greater safety with synchronized as compared to asynchronized … Inter-hospital transfers are an important pathway toward improving outcomes for critically ill patients who present to …
Perspective on Safety February 1, 2010
Clear health communication is increasingly recognized as essential for promoting patient safety. Yet according to a recent Joint Commission report, What Did the Doctor Say?
Thomas J. Nasca, MD, is the executive director and chief executive officer of the Accreditation Council for Graduate Medical Education (ACGME). Prior to joining the ACGME in 2007, Dr. Nasca, a nephrologist, was dean of Jefferson Medical College and Senior Vice President for Academic Affairs of Thomas Jefferson University. We asked him to speak with us about the role of the ACGME in patient safety.
Perspective on Safety April 1, 2013
This article discusses evidence surrounding the impact of resident duty hour limits on safety in health care.
Christopher P. Landrigan, MD, MPH, of Brigham and Women's Hospital has performed key studies on how sleep deprivation affects clinicians and strategies to mitigate such fatigue to improve patient safety, including seminal articles published in the New England Journal of Medicine in 2004 and 2010.
Barbanti-Brodano G, Griffoni C, Halme J, et al. Eur Spine J. 2019.
… Study … European spine journal : official publication of the European Spine Society, the European Spinal Deformity … Society … Eur Spine J … Checklists are one tool for improving communication and reducing risk of adverse outcomes. The World Health Organization Surgical Safety Checklist has been previously studied in various …

Heiss K, ed. Semin Pediatr Surg. 2015;24:265-326.

… principles, such as system-oriented accident prevention, safety culture , and professionalism , and discuss these concepts in the context of pediatric surgery to support progress in this setting. … … … Heiss K, ed. Semin Pediatr Surg. 2015;24:265-326. … Improving Pediatric Surgery Quality and Outcomes in the 21st …
WebM&M Case March 25, 2020
… Disclosure of Relevant Financial Relationships: … As a provider … for Continuing Medical Education (ACCME), the University of California, Davis, Health must ensure balance, … emergency physicians immediately consulted the Vascular Surgery team, which evaluated the patient at 7:30am and …
Perspective on Safety September 24, 2024
… Oath, “First do no harm,” serves as the cornerstone of medical ethics and core value of healthcare: Patients … them continue to be identified and reported, some patient safety advocates have espoused a zero harm principle. Zero … seeks safer care. … Point … Zero Harm Goals Contribute to Improving Patient Safety Zero harm goes beyond simply …
Carole Stockmeier photo

Carole Stockmeier, MHA, BS, is the Senior Vice President of Safety and Reliability Solutions at Press Ganey, with over 20 years of experience in safety science and high reliability organizations. We spoke to her about zero harm and patient safety.

Eric Thomas photo

Eric Thomas, MD, MPH, is the Director of the University of Texas Houston Memorial Hermann Center for Healthcare Quality and Safety and is Associate Dean for Healthcare Quality. We spoke to him about zero harm and patient safety.

Patient Safety Primer January 29, 2020
… information, review their performance, proactively flag safety concerns, increase accountability, and ensure that … staff in problem identification and build a culture of collaboration and quality, thereby enhancing the ability … Boston, MA. 2015. Brady PW, Muething S, Kotagal U, et al. Improving situation awareness to reduce unrecognized clinical …
Perspective on Safety January 31, 2024

This perspective discusses patient safety in office-based care settings, where most patients get their healthcare. We discuss patient safety events that arise in routine office-based settings and those more particular to procedures performed in office-based ambulatory surgery centers. Communication strategies can mitigate safety risks and can be applied in many healthcare settings.

Richard Ricciardi

Richard Ricciardi is the associate dean for clinical practice and community engagement and the executive director of the Center for Health Policy and Media Engagement at the George Washington University. He has served as the director of the Division of Practice Improvement and senior advisor for nursing at AHRQ, and he maintains a part-time clinical practice at Mercy Health Clinic. We spoke to him on patient safety in office-based settings.