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psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
January 12, 2022 - organizations dedicated to improving patient safety and healthcare quality that serve to collect and analyze
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psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa
January 01, 2017 - The goal was identify, analyze, share, and implement within 4 days of an incident occurring anywhere
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psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
September 01, 2011 - Incident Reporting: More Attention to the Safety Action Feedback Loop, Please
Teryl K. Nuckols, MD, MSHS | September 1, 2011
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Nuckols TK. Incident Reporting: More Attention to the …
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psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
September 01, 2011 - In Conversation With…Kaveh G. Shojania, MD
September 1, 2011
Also Read an Essay
Citation Text:
In Conversation With…Kaveh G. Shojania, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
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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.
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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…
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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.
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Format:
Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnot…
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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
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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.
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psnet.ahrq.gov/web-mm/errors-sepsis-management
November 03, 2015 - SPOTLIGHT CASE
Errors in Sepsis Management
Citation Text:
Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/33770/psn-pdf
August 01, 2014 - In Conversation With… Urmimala Sarkar, MD, MPH
August 1, 2014
In Conversation With… Urmimala Sarkar, MD, MPH. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
Editor's note: Urmimala Sarkar, MD, MPH, is associate professor of medicine at the University of
California, S…
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psnet.ahrq.gov/node/851870/psn-pdf
July 31, 2023 - In Conversation with... Regina Hoffman about Building
Capacity for Patient Safety
July 31, 2023
In Conversation with.. Regina Hoffman about Building Capacity for Patient Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-building-capacity-patient-safety
Editor’s no…
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psnet.ahrq.gov/node/49738/psn-pdf
August 21, 2015 - Privacy or Safety?
August 21, 2015
Halamka JD, McGraw D. Privacy or Safety? PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/privacy-or-safety
Case Objectives
Understand that the HIPAA Omnibus Rule is an enabler of data sharing, not a barrier.
Review common misconceptions about privacy rules.
Understand the…
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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.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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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 …
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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.
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DOI Google Scholar…
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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.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML En…
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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.
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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.
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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…