U.S. Department of Health and Human Services
Agency for Healthcare Research and Quality: Advancing Excellence in Health Care
Sign up for a Free Account
Joint Commission and the American Nurses Association. Oakbrook, IL: Joint Commission Resources, Inc; 2018. ISBN: 9781635850611.
Nurses have an important role in ensuring patient safety on the front line. This book provides strategies for nurses to identify and help prevent sentinel events, with each chapter discussing prevention of a specific type of event.
8th Annual Oregon Patient Safety Forum.
Oregon Patient Safety Commission. March 15, 2019; Sentinel Hotel, Portland, OR.
Harveian Oration 2018: improving quality and safety in healthcare.
Dixon-Woods M. Clin Med (Lond). 2019;19:47-56.
Individual Clinician Performance Issues
Long-term Care and Patient Safety
Triggers and Trigger Tools
Patient Safety: Global Action on Patient Safety.
Executive Board EB144/29 144th session. Geneva, Switzerland: World Health Organization; December 12, 2018.
Quality improvement priorities for safer out-of-hours palliative care: lessons from a mixed-methods analysis of a national incident-reporting database.
Williams H, Donaldson LJ, Noble S, et al. Palliat Med. 2019;33:346-356.
Framework for Effective Board Governance of Health System Quality.
Daley Ullem E, Gandhi TK, Mate K, Whittington J, Renton M, Huebner J. IHI White Paper. Boston, MA: Institute for Healthcare Improvement; 2018.
Preventing central line–associated bloodstream infections in the intensive care unit: application of high-reliability principles.
McCraw B, Crutcher T, Polancich S, Jones P. J Healthc Qual. 2018;40:392-397.
Association of opioid prescribing with opioid consumption after surgery in Michigan.
Howard R, Fry B, Gunaseelan V, et al. JAMA Surg. 2019;154:e184234.
The Kentucky Institute for Patient Safety and Quality.
2501 Nelson Miller Parkway. Louisville, KY, 40223.
Reducing Diagnostic Errors in Primary Care Pediatrics (Project RedDE!) Toolkit.
Itasca, IL: American Academy of Pediatrics; 2018.
IV push medications survey results—part 1 and part 2.
ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.
What we can do about maternal mortality—and how to do it quickly.
Mann S, Hollier LM, McKay K, Brown H. N Engl J Med. 2018;379:1689-1691.
National Healthcare Quality and Disparities Report: Chartbook on Patient Safety.
Gray D, Azam I. Rockville, MD: Agency for Healthcare Research and Quality; October 2018. AHRQ Publication No. 18(19)-0033-4-EF.
Quality, Value, and Patient Safety in Orthopedic Surgery.
Azar FM, ed. Orthop Clin North Am. 2018;49:A1-A8,389-552.
A Patient-Safe Future.
Patient Safety Learning: London, UK; September 2018.
Crossing the Global Quality Chasm: Improving Health Care Worldwide.
Committee on Improving the Quality of Health Care Globally. National Academies of Sciences, Engineering, and Medicine. Washington DC: National Academies Press; August 2018. ISBN: 9780309483087.
Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study.
Schnipper JL, Mixon A, Stein J, et al. BMJ Qual Saf. 2018;27:954-964.
Transforming concepts in patient safety: a progress report.
Gandhi TK, Kaplan GS, Leape L, et al. BMJ Qual Saf. 2018;27:1019-1026.
No Place Like Home: Advancing the Safety of Care in the Home.
Boston, MA: Institute for Healthcare Improvement; 2018.
Patient safety initiatives in obstetrics: a rapid review.
Antony J, Zarin W, Pham B, et al. BMJ Open. 2018;8:e020170.
2017 John M. Eisenberg Patient Safety and Quality Awards.
Jt Comm J Qual Patient Saf. 2018;44:373-400.
Surgical fires: decreasing incidence relies on continued prevention efforts.
Bruley ME, Arnold TV, Finley E, Deutsch ES, Treadwell JR. PA-PSRS Pa Patient Saf Advis. June 2018;15.
Quality Improvement Series.
British Medical Journal.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364