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psnet.ahrq.gov/node/867655/psn-pdf
February 26, 2025 - action emphasizes that meaningful and lasting improvements in patient safety
require a total systems approach
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
August 01, 2012 - A clinician-based approach.
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psnet.ahrq.gov/node/837785/psn-pdf
August 05, 2022 - A human-centered approach that focuses on heterogenous user populations is
required to yield a satisfactory
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psnet.ahrq.gov/node/60167/psn-pdf
April 12, 2024 - The IDEAL discharge
planning strategy is one approach emphasizing patient and family engagement in discharge
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - In the past 2 years, we have seen a movement toward a hospital– and health system–wide focus on and approach
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psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
January 01, 2018 - care setting is documented to be 23) The CDC also recommends streamlined counseling using an "opt-out" approach … This opt-out approach is similar to recommendations for routine screening in the prenatal setting.
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psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
March 01, 2015 - HSMR: A New Approach for Measuring Hospital Mortality Trends in Canada. … you think through what the goals are and how to balance measurement for transparency, as a regulatory approach
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psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
February 19, 2020 - a gait disturbance.( 15 ) Because many factors place patients at risk for falling, a multifactorial approach … A new approach to fall prevention in inpatient care: implementing remote audiovisual monitoring of at-risk
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - Approach to Improving Safety & Patient Safety Target Swiss Cheese Model Missed diagnoses are one of the … system for closing the loop on important non-urgent radiology findings: a multidisciplinary system-wide approach
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psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
December 23, 2020 - particularly prone to error. 11,12
System Errors Contributing to this Medication Error
A systems approach … Systems Change Needed/Quality Improvement Approach
Streamlined TPN re-ordering process
The
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psnet.ahrq.gov/Issues
June 23, 2021 - Healthcare professionals' encounters with ethnic minority patients: the critical incident approach … Safe opioid prescribing: a prognostic machine learning approach to predicting 30-day risk after an opioid
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psnet.ahrq.gov/issues
June 23, 2021 - Healthcare professionals' encounters with ethnic minority patients: the critical incident approach … Safe opioid prescribing: a prognostic machine learning approach to predicting 30-day risk after an opioid
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psnet.ahrq.gov/node/73899/psn-pdf
September 29, 2021 - the CDC has published conversion factors for calculating morphine milligram-equivalents (MME),
this approach … drug's absorption, metabolism, and relative analgesic potency
necessitates a highly individualized approach
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psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
December 14, 2022 - The CMS National Quality Strategy: A Person-Centered Approach to Improving Quality. June 6, 2022. … https://www.cms.gov/blog/cms-national-quality-strategy-person-centered-approach-improving-quality 11
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psnet.ahrq.gov/perspective/measuring-patient-safety
December 14, 2022 - The CMS National Quality Strategy: A Person-Centered Approach to Improving Quality. June 6, 2022. … https://www.cms.gov/blog/cms-national-quality-strategy-person-centered-approach-improving-quality 11
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psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
March 01, 2019 - performed within the hospital.( 9 )
Middle managers are key to successfully transforming to a systems approach … October 13, 2021
Developing expert medical teams: toward an evidence-based approach.
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psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
December 01, 2006 - principles from management science instructs us toward a more contingent, pragmatic, and action-oriented approach … This modest approach may frustrate those who see the dysfunctions of the health care workplace—for example
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psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
December 01, 2006 - principles from management science instructs us toward a more contingent, pragmatic, and action-oriented approach … This modest approach may frustrate those who see the dysfunctions of the health care workplace—for example
-
psnet.ahrq.gov/node/49764/psn-pdf
June 01, 2016 - Communication With Consultants
June 1, 2016
Cohn SL. Communication With Consultants. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/communication-consultants
The Case
A 30-year-old pregnant woman presented to the emergency department (ED) with nausea, headaches, and
fevers. Her laboratory studies were nota…
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psnet.ahrq.gov/node/33586/psn-pdf
December 15, 2024 - Alert Fatigue
December 15, 2024
Alert Fatigue. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/alert-fatigue
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
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