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  1. psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
    July 17, 2024 - With this as the goal, the suspected error should be reported to organizational leadership and then analyzed
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33736/psn-pdf
    September 01, 2012 - Several years later, I analyzed the effect of turnover, drawing upon some of the research on staffing
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33664/psn-pdf
    March 01, 2008 - We have analyzed all data for the last 15 years, and our major and minor complication rate for all of
  4. psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
    September 27, 2023 - reviewed for appropriateness as well as the frequency of review. 9 Override reports should be routinely analyzed
  5. psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
    January 22, 2020 - In order to provide a deeper understanding of such interactions, we analyzed data from responses of more
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865610/psn-pdf
    April 24, 2024 - Data were collected from 2014 to 2018 and analyzed from April 2022 to December 2022.3 The trial included
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33715/psn-pdf
    July 01, 2011 - Becoming a Patient Safety Organization July 1, 2011 Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/becoming-patient-safety-organization Perspective While I was the first employee of the California Hospital Patient Safety Organization (CHPSO), its story …
  8. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
    October 01, 2010 - Spotlight Case July 2008 Spotlight Case October 2010 Dangerous Dialysis * * Source and Credits This presentation is based on the October 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jean L. Holley, MD, University of Illinois, Urbana-…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866621/psn-pdf
    August 28, 2024 - Application of Safety-II Principles August 28, 2024 Venkatesan C, Helak K, Sousane Z, et al. Application of Safety-II Principles. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/application-safety-ii-principles Traditional approaches to patient safety have often been reactive rather than proactive, seeki…
  10. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
    August 01, 2009 - Spotlight Case July 2008 Spotlight Case Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care * Source and Credits This presentation is based on the August 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME/CEU credit is available Commentary by: …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49409/psn-pdf
    July 01, 2003 - Feeling No Pain July 1, 2003 Bogner MS. Feeling No Pain. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/feeling-no-pain The Case A 33-year-old female underwent hysterectomy for refractory endometriosis. For pain post-operatively, the patient was placed on a Patient-Controlled Analgesia (PCA) pump containin…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49390/psn-pdf
    February 01, 2003 - Flying Object Hits MRI February 1, 2003 Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/flying-object-hits-mri The Case A child was brought to the Magnetic Resonance Imaging (MRI) room for a brain scan. Accompanied by an anesthesiologist, the child was receiving…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49839/psn-pdf
    August 01, 2018 - Mixup Beyond the Medication Label August 1, 2018 Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/mixup-beyond-medication-label The Case An 80-year-old man was admitted to a hospital for recurrent hypoglycemia. He had been seen at another hospi…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866395/psn-pdf
    July 23, 2024 - Rescue Improvement Conference Innovation Summary July 23, 2024 https://psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary Summary The Rescue Improvement Conference (RIC)1 was designed at the University of Michigan to address failure to rescue with a particular focus on communication and com…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49697/psn-pdf
    December 01, 2013 - Check the Anesthesia Machine December 1, 2013 Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/check-anesthesia-machine The Case A 62-year-old man with weight of 134 kg (body mass index [BMI] of 40) and history of hypertension, diabetes, sleep apnea…
  16. psnet.ahrq.gov/primer/national-patient-safety-goals
    January 16, 2025 - National Patient Safety Goals Citation Text: Shaikh U. National Patient Safety Goals. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…
  17. psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
    November 01, 2006 - In Conversation With...Donald A. Norman, PhD November 1, 2006  Also Read an Essay Citation Text: In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006.In Conversation With...Donald A. Norman, PhD. PSNet [internet]. Rockville (MD): Agency for Healthca…
  18. psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms-0
    December 01, 2017 - In Conversation With… Karl Bilimoria, MD, MS August 1, 2017  Also Read an Essay Citation Text: In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
  19. psnet.ahrq.gov/perspective/evolution-patient-safety-surgery
    August 01, 2017 - The Evolution of Patient Safety in Surgery Robert M. Wachter, MD | December 1, 2017  Also Read a Conversation View more articles from the same authors. Citation Text: Wachter R. The Evolution of Patient Safety in Surgery. PSNet [internet]. Rockville (MD): Agency…
  20. psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md
    August 01, 2010 - In Conversation with...Richard P. Shannon, MD August 1, 2010  Also Read an Essay Citation Text: In Conversation with..Richard P. Shannon, MD. PSNet [internet]. 2010.In Conversation with...Richard P. Shannon, MD. PSNet [internet]. Rockville (MD): Agency for Healthc…

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