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psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
April 08, 2019 - and (ii) What are the main barriers to achieving interoperability across information technology systems
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psnet.ahrq.gov/node/73456/psn-pdf
June 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult
Intubation and Severe Hypoxemia
June 30, 2021
Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat…
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psnet.ahrq.gov/node/49864/psn-pdf
June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You
in Training About Feedback and Burnout
June 1, 2019
Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About
Feedback and Burnout. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…
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psnet.ahrq.gov/node/50392/psn-pdf
September 01, 2019 - In Conversation With… Shantanu Agrawal, MD, MPhil
September 1, 2019
In Conversation With… Shantanu Agrawal, MD, MPhil. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil
Editor's note: Dr. Agrawal is president and CEO of the National Quality Forum (NQF). He is the form…
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psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
September 15, 2024 - COVID-19: Team and Human Factors to Improve Safety
Citation Text:
Zipperer L. COVID-19: Team and Human Factors to Improve Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
April 01, 2006 - Coming Undone: Failure of Closure Device
Citation Text:
Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/issue/trends-pregnancy-related-deaths-and-federal-efforts-reduce-them
May 27, 2020 - Book/Report
Trends in Pregnancy-Related Deaths and Federal Efforts to Reduce Them.
Citation Text:
Trends in Pregnancy-Related Deaths and Federal Efforts to Reduce Them. Washington, DC: United States Government Accountability Office; March 2020. Publication GAO-20-248.
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psnet.ahrq.gov/issue/how-identify-and-address-unsafe-conditions-associated-health-it
June 29, 2016 - Book/Report
How to Identify and Address Unsafe Conditions Associated With Health IT.
Citation Text:
How to Identify and Address Unsafe Conditions Associated With Health IT. Wallace C, Zimmer KP, Possanza L, Giannini R, Solomon R. Washington, DC: Office of the National Coordinator for…
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psnet.ahrq.gov/issue/call-excellence
May 20, 2009 - Commentary
A call to excellence.
Citation Text:
Clancy CM, Scully T. A call to excellence. Health Aff (Millwood). 2003;22(2):113-5.
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psnet.ahrq.gov/issue/leadership-committed-safety
December 23, 2016 - Sentinel Event Alerts
Leadership committed to safety.
Citation Text:
Leadership committed to safety. Sentinel Event Alert. August 27, 2009;(43):1-3.
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psnet.ahrq.gov/issue/drug-shortages-public-health-threat-continues-despite-efforts-help-ensure-product
March 19, 2014 - Book/Report
Drug Shortages: Public Health Threat Continues, Despite Efforts to Help Ensure Product Availability.
Citation Text:
Drug Shortages: Public Health Threat Continues, Despite Efforts to Help Ensure Product Availability. Washington, DC: United States Government Accountability Off…
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psnet.ahrq.gov/issue/physician-owned-specialty-hospitals-ability-manage-medical-emergencies
February 18, 2009 - Book/Report
Physician-Owned Specialty Hospital's Ability to Manage Medical Emergencies.
Citation Text:
Physician-Owned Specialty Hospital's Ability to Manage Medical Emergencies. Levinson DR. Washington DC: US Department of Health and Human Services, Office of Inspector General. …
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psnet.ahrq.gov/issue/new-hhs-data-shows-major-strides-made-patient-safety-leading-improved-care-and-savings
October 31, 2014 - Book/Report
New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings.
Citation Text:
New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings. Washington, DC: US Department of Health and Human Services; May 7, 2014…
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psnet.ahrq.gov/issue/adverse-events-hospitals-methods-identifying-events
February 18, 2009 - Book/Report
Adverse Events in Hospitals: Methods for Identifying Events.
Citation Text:
Adverse Events in Hospitals: Methods for Identifying Events. Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; March 2010. Report No. OEI-06…
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psnet.ahrq.gov/issue/health-information-technology-united-states-information-base-progress
April 04, 2018 - Book/Report
Health Information Technology in the United States: The Information Base for Progress.
Citation Text:
Health Information Technology in the United States: The Information Base for Progress. Blumenthal D, DesRoches C, Donelan K, et al. Princeton, NJ: Robert Wood Johnson F…
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psnet.ahrq.gov/issue/safety-care-caregivers-cancer-patients
March 02, 2012 - January 15, 2014
Achieving rapid door-to-balloon times: how top hospitals improve complex
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psnet.ahrq.gov/issue/safety-culture-nursing-homes-opinions-top-managers
June 02, 2010 - June 29, 2011
Achieving quality improvement in the nursing home: influence of nursing
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psnet.ahrq.gov/issue/identifying-and-understanding-ways-address-impact-racism-patient-safety-health-care-settings
May 21, 2014 - May 21, 2014
Achieving Strong Teamwork Practices in Hospital Labor and Delivery Units
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psnet.ahrq.gov/issue/examining-relationship-among-ambulatory-surgical-settings-work-environment-nurses
March 29, 2017 - June 12, 2013
Achieving quality improvement in the nursing home: influence of nursing
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psnet.ahrq.gov/issue/medication-safety-teams-guided-implementation-electronic-medication-administration-records
September 27, 2016 - September 4, 2010
Achieving quality improvement in the nursing home: influence of nursing