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  1. psnet.ahrq.gov/perspective/health-equity-and-maternal-health
    October 06, 2021 - However, when assessing maternal safety, it is also essential to also take a whole-person view. … from the patient’s entry point into the hospital and then through all of the steps of the process and assessing
  2. psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
    October 06, 2021 - from the patient’s entry point into the hospital and then through all of the steps of the process and assessing … However, when assessing maternal safety, it is also essential to also take a whole-person view.
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863650/psn-pdf
    February 28, 2024 - ABCDEF Bundle + Data Literacy Training, Performance Measurement Tracking, and Performance Feedback February 28, 2024 https://psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking- and-performance Summary To improve patient care and outcomes in the intensive care unit (ICU…
  4. psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
    December 15, 2024 - Deprescribing as a Patient Safety Strategy Citation Text: Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33736/psn-pdf
    September 01, 2012 - In Conversation With… Jack Needleman, PhD September 1, 2012 In Conversation With… Jack Needleman, PhD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-jack-needleman-phd Editor's note: Jack Needleman, PhD, is a Professor in the Department of Health Policy and Management at UCLA School of P…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33806/psn-pdf
    April 01, 2016 - In Conversation With… Amy J. Starmer, MD, MPH April 1, 2016 In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph Editor's note: Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of Pediatrics a…
  7. psnet.ahrq.gov/web-mm/july-syndrome
    July 01, 2011 - July Syndrome Citation Text: Young JQ. July Syndrome. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS D…
  8. psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care 1 Source and Credits This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Elizabeth Gould, NP-C, COR…
  9. psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
    March 01, 2006 - Hyperbilirubinemia Refractory to Phototherapy Citation Text: Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39975/psn-pdf
    March 03, 2011 - Communication failure in the operating room. March 3, 2011 Halverson AL, Casey JT, Andersson J, et al. Communication failure in the operating room. Surgery. 2011;149(3):305-310. doi:10.1016/j.surg.2010.07.051. https://psnet.ahrq.gov/issue/communication-failure-operating-room Communication failures are a well-chara…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44947/psn-pdf
    November 18, 2016 - Impact of the 2011 ACGME resident duty hour reform on hospital patient experience and processes-of-care. November 18, 2016 Rajaram R, Saadat L, Chung JW, et al. Impact of the 2011 ACGME resident duty hour reform on hospital patient experience and processes-of-care. BMJ Qual Saf. 2016;25(12):962-970. doi:10.1136/bmj…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74102/psn-pdf
    January 01, 2022 - Workforce planning and safe workload in sterile compounding hospital pharmacy services. November 24, 2021 Chaker A, Omair I, Mohamed WH, et al. Workforce planning and safe workload in sterile compounding hospital pharmacy services. Am J Health Syst Pharm. 2022;79(3):187–192. doi:10.1093/ajhp/zxab379. https://psnet…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35805/psn-pdf
    January 02, 2017 - Getting the board on board: engaging hospital boards in quality and patient safety. January 2, 2017 Joshi MS, Hines S. Getting the board on board: Engaging hospital boards in quality and patient safety. Jt Comm J Qual Patient Saf. 2006;32(4):179-87. https://psnet.ahrq.gov/issue/getting-board-board-engaging-hospita…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45848/psn-pdf
    November 19, 2018 - New Horizons in Patient Safety: Understanding Communication: Case Studies for Physicians. November 19, 2018 Hannawa AF, Wu AW, Juhasz RS, eds. Berlin, Germany: DeGruyter; 2017. ISBN: 9783110455014. https://psnet.ahrq.gov/issue/new-horizons-patient-safety-understanding-communication-case-studies- physicians Poor c…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46530/psn-pdf
    February 03, 2018 - Identifying and characterizing preventable adverse drug events for prioritizing pharmacist intervention in hospitals. February 3, 2018 Jeon N, Staley B, Johns T, et al. Identifying and characterizing preventable adverse drug events for prioritizing pharmacist intervention in hospitals. Am J Health Syst Pharm. 2017…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60359/psn-pdf
    May 20, 2020 - Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. May 20, 2020 ISMP Medication Safety Alert! Acute care edition. May 7, 2020;25(9). https://psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone- overdose Lack of familiarity with sm…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46388/psn-pdf
    September 24, 2017 - Recognizing and responding to the "toxic" work environment: worker safety, patient safety, and abuse/neglect in nursing homes. September 24, 2017 Pickering CEZ, Nurenberg K, Schiamberg L. Recognizing and Responding to the "Toxic" Work Environment: Worker Safety, Patient Safety, and Abuse/Neglect in Nursing Homes. …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865583/psn-pdf
    April 17, 2024 - Impact of repeated reimbursement penalties on hospital total quality scores. April 17, 2024 Brewer A, Hughes MC, Patel KN. Impact of repeated reimbursement penalties on hospital total quality scores. J Patient Saf. 2024;20(3):198-201. doi:10.1097/pts.0000000000001199. https://psnet.ahrq.gov/issue/impact-repeated-r…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72600/psn-pdf
    December 23, 2020 - Improving hospital safety culture for falls prevention through interdisciplinary health education. December 23, 2020 Lopez-Jeng C, Eberth SD. Improving hospital safety culture for falls prevention through interdisciplinary health education. Health Promot Pract. 2020;21(6):918-925. doi:10.1177/1524839919840337. htt…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47400/psn-pdf
    November 28, 2018 - Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. November 28, 2018 Müller M, Jürgens J, Redaèlli M, et al. Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. BMJ Open. 2018;8(8):e022202. doi:10.1136/bmjopen-2018-022202…

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