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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847934/psn-pdf
    April 26, 2023 - Patient Safety Indicators April 26, 2023 Tokareva I, Romano P. Patient Safety Indicators. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/patient-safety-indicators Background Over the past 25 years, policymakers and providers, payers, and purchasers of health care have increasingly focused attention on pati…
  2. psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
    August 28, 2024 - Root Cause Analysis Gone Wrong Citation Text: Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML E…
  3. psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
    May 16, 2022 - Wrong Catheter in the Right Patient Citation Text: Chia C, Molla M. Wrong Catheter in the Right Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…
  4. psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
    January 01, 2024 - Spotlight Spotlight A Fatal Twist in Pseudohyperkalemia 1 Source and Credits This presentation is based on the August 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Justin L. Devera, MD, David K. Barnes, MD, FACEP, and William R. Le…
  5. psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
    May 29, 2024 - Getting the Diagnosis Both Right and Wrong Citation Text: Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3…
  6. psnet.ahrq.gov/web-mm/check-wristband
    August 03, 2009 - Check the Wristband Citation Text: Rosenthal M. Check the Wristband. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45190/psn-pdf
    February 15, 2017 - Biases in detection of apparent "weekend effect" on outcome with administrative coding data: population based study of stroke. February 15, 2017 Li L, Rothwell PM, Study OV. Biases in detection of apparent "weekend effect" on outcome with administrative coding data: population based study of stroke. BMJ. 2016;353:…
  8. psnet.ahrq.gov/issue/discontinuity-and-disaster-gaps-and-negotiation-culpability-medication-delivery
    June 24, 2020 - Commentary Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. Citation Text: Dekker SWA. Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. J Law Med Ethics. 2007;35(3):463-70. Copy Citation Format:…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40725/psn-pdf
    October 16, 2012 - Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. October 16, 2012 Bell CM, Brener SS, Gunraj N, et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA. 2011;306(8):840-7. doi:10.10…
  10. psnet.ahrq.gov/issue/strategies-learning-failure
    September 25, 2024 - Commentary Classic Strategies for learning from failure. Citation Text: Edmondson A. Strategies of learning from failure. Harv Bus Rev. 2011;89(4):48-55, 137. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnot…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33612/psn-pdf
    May 01, 2005 - We embedded in our practice a robust root cause analysis system to analyze critical incidents, report
  12. psnet.ahrq.gov/issue/patient-safety-7
    November 16, 2015 - Book/Report Patient Safety. Citation Text: Patient Safety. Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I. Copy Citation Save Save to your library Print …
  13. psnet.ahrq.gov/issue/nurses-role-patient-safety
    June 09, 2011 - Commentary Nurses' role in patient safety. Citation Text: Hughes RG, Clancy CM. Nurses' role in patient safety. J Nurs Care Qual. 2009;24(1):1-4. doi:10.1097/NCQ.0b013e31818f55c7. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …
  14. psnet.ahrq.gov/issue/systematic-review-incidence-and-characteristics-preventable-adverse-drug-events-ambulatory
    July 15, 2010 - Review Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care. Citation Text: Thomsen LA, Winterstein AG, S⊘ndergaard B, et al. Systematic Review of the Incidence and Characteristics of Preventable Adverse Drug Events in Ambulatory …
  15. psnet.ahrq.gov/issue/nursing-student-errors-and-near-misses-three-years-data
    October 20, 2021 - Study Nursing student errors and near misses: three years of data. Citation Text: Silvestre JH, Spector ND. Nursing student errors and near misses: three years of data. J Nurs Educ. 2023;62(1):12-19. doi:10.3928/01484834-20221109-05. Copy Citation Format: DOI Google Scholar…
  16. psnet.ahrq.gov/issue/ambulance-stretcher-adverse-events
    March 23, 2011 - Study Ambulance stretcher adverse events. Citation Text: Wang HE, Weaver MD, Abo BN, et al. Ambulance stretcher adverse events. Qual Saf Health Care. 2009;18(3):213-216. doi:10.1136/qshc.2007.024562. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML En…
  17. psnet.ahrq.gov/issue/complication-rates-weekends-and-weekdays-us-hospitals
    August 31, 2011 - Study Complication rates on weekends and weekdays in US hospitals. Citation Text: Bendavid E, Kaganova Y, Needleman J, et al. Complication rates on weekends and weekdays in US hospitals. Am J Med. 2007;120(5):422-8. Copy Citation Format: Google Scholar PubMed BibTeX EndNo…
  18. psnet.ahrq.gov/issue/using-six-sigma-reduce-medication-errors-home-delivery-pharmacy-service
    November 18, 2015 - Study Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. Citation Text: Castle L, Franzblau-Isaac E, Paulsen J. Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. Jt Comm J Qual Patient Saf. 2005;31(6):319-24. Copy Citation …
  19. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.72_slideshow.ppt
    September 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case September 2004 Poor Prognosis? Source and Credits This presentation is based on the September 2004 AHRQ WebM&M Spotlight Case in Surgery See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Elizabeth B. Lamont, M…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38956/psn-pdf
    March 18, 2015 - Safety in Doses. March 18, 2015 London, UK: National Patient Safety Agency; 2009. ISBN: 9781906624088. https://psnet.ahrq.gov/issue/safety-doses This publication analyzes 72,482 medication incidents reported to the National Health Service and highlights areas for improvement and prevention. https://psnet.ahrq.gov…

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