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psnet.ahrq.gov/node/61124/psn-pdf
November 11, 2020 - Using Twitter to assess patient takes on patient
experience.
November 11, 2020
Heath S. Patient Engagement HIT. October 29, 2020.
https://psnet.ahrq.gov/issue/using-twitter-assess-patient-takes-patient-experience
Twitter is evolving as a useful data source for patient safety. This news story discusses an examinati…
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psnet.ahrq.gov/node/34752/psn-pdf
November 18, 2015 - Demanding Medical Excellence. Doctors and
Accountability in the Information Age.
November 18, 2015
Millenson ML. Chicago, IL: University of Chicago Press; 1999. ISBN: 9780226525884.
https://psnet.ahrq.gov/issue/demanding-medical-excellence-doctors-and-accountability-information-age
Millenson, a Pulitzer-nomin…
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psnet.ahrq.gov/node/39378/psn-pdf
March 17, 2010 - Exploring emergency physician–hospitalist handoff
interactions: development of the Handoff Communication
Assessment.
March 17, 2010
Apker J, Mallak LA, Applegate B, et al. Exploring emergency physician-hospitalist handoff interactions:
development of the Handoff Communication Assessment. Ann Emerg Med. 2010;55(2):…
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psnet.ahrq.gov/node/847058/psn-pdf
April 05, 2023 - Care Delivery within Community Mental Health Teams.
April 5, 2023
Farnborough, UK: Healthcare Safety Investigation Branch; March 2023.
https://psnet.ahrq.gov/issue/care-delivery-within-community-mental-health-teams
Patient suicide is a sentinel event. This report examines a suicide incident that identified problems…
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psnet.ahrq.gov/issue/systematic-proactive-risk-assessment-hazards-surgical-wards-quantitative-study
August 15, 2013 - Study
A systematic proactive risk assessment of hazards in surgical wards: a quantitative study.
Citation Text:
Anderson O, Brodie A, Vincent CA, et al. A systematic proactive risk assessment of hazards in surgical wards: a quantitative study. Ann Surg. 2012;255(6):1086-92. doi:10.1097…
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psnet.ahrq.gov/issue/assessment-use-patient-vital-sign-data-preventing-misidentification-and-medical-errors
February 16, 2022 - Commentary
Assessment of the use of patient vital sign data for preventing misidentification and medical errors.
Citation Text:
Maul J, Straub J. Assessment of the use of patient vital sign data for preventing misidentification and medical errors. Healthcare (Basel). 2022;10(12):2440. do…
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psnet.ahrq.gov/issue/sbar-mm-feasible-reliable-and-valid-tool-assess-quality-surgical-morbidity-and-mortality
July 02, 2014 - Study
SBAR M&M: a feasible, reliable, and valid tool to assess the quality of, surgical morbidity and mortality conference presentations.
Citation Text:
Mitchell EL, Lee DY, Arora S, et al. SBAR M&M: a feasible, reliable, and valid tool to assess the quality of, surgical morbidity and …
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psnet.ahrq.gov/issue/optimal-preoperative-assessment-geriatric-surgical-patient-best-practices-guideline-american
July 13, 2010 - Commentary
Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society.
Citation Text:
Chow WB, Rosenthal RA, Merkow RP, et al. Optim…
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psnet.ahrq.gov/issue/guidelines-us-hospitals-and-clinicians-assessment-electronic-health-record-safety-using-safer
June 24, 2020 - Commentary
Guidelines for US hospitals and clinicians on assessment of electronic health record safety using SAFER Guides.
Citation Text:
Sittig DF, Sengstack P, Singh H. Guidelines for US hospitals and clinicians on assessment of electronic health record safety using SAFER Guides. JAMA.…
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psnet.ahrq.gov/issue/institute-safe-medication-practices-and-poison-control-centers-collaborating-prevent
April 22, 2017 - Commentary
The Institute for Safe Medication Practices and poison control centers: collaborating to prevent medication errors and unintentional poisonings.
Citation Text:
Vaida AJ. The Institute for Safe Medication Practices and Poison Control Centers: Collaborating to Prevent Medication…
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psnet.ahrq.gov/issue/oncology-medication-safety-3d-status-report-2008
March 26, 2015 - Study
Oncology medication safety: a 3D status report 2008.
Citation Text:
Johnson PE, Chambers C, Vaida AJ. Oncology medication safety: a 3D status report 2008. J Oncol Pharm Pract. 2008;14(4):169-80. doi:10.1177/1078155208097634.
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DOI Google Scholar …
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psnet.ahrq.gov/issue/management-anesthesia-equipment-failure-simulation-based-resident-skill-assessment
December 20, 2017 - Study
Management of anesthesia equipment failure: a simulation-based resident skill assessment.
Citation Text:
Waldrop WB, Murray DJ, Boulet JR, et al. Management of Anesthesia Equipment Failure: A Simulation-Based Resident Skill Assessment. Anesthesia & Analgesia. 2009;109(2). doi:10.…
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psnet.ahrq.gov/issue/assessing-safety-culture-care-homes-multimethod-evaluation-adaptation-face-validity-and
June 28, 2017 - Study
Assessing the safety culture of care homes: a multimethod evaluation of the adaptation, face validity and feasibility of the Manchester Patient Safety Framework.
Citation Text:
Marshall M, Cruickshank L, Shand J, et al. Assessing the safety culture of care homes: a multimethod eval…
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psnet.ahrq.gov/issue/proactive-risk-assessment-surgical-site-infections-ambulatory-surgery-centers
April 13, 2022 - Study
Proactive risk assessment of surgical site infections in ambulatory surgery centers.
Citation Text:
Bish EK, Azadeh-Fard N, Steighner LA, et al. Proactive Risk Assessment of Surgical Site Infections in Ambulatory Surgery Centers. J Patient Saf. 2014;13(2). doi:10.1097/pts.000000000…
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psnet.ahrq.gov/issue/toward-translation-systems-thinking-methods-patient-safety-practice-assessing-validity-net
April 21, 2021 - Study
Toward the translation of systems thinking methods in patient safety practice: assessing the validity of Net-HARMS and AcciMap.
Citation Text:
Salmon PM, King B, Hulme A, et al. Toward the translation of systems thinking methods in patient safety practice: assessing the validity of…
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psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd
February 26, 2025 - In Conversation With… Ann L. Hendrich, RN, PhD
December 1, 2011
Citation Text:
In Conversation With… Ann L. Hendrich, RN, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/865466/psn-pdf
March 27, 2024 - These
disparities may further feed into, and become entrenched in, AI assessments of its own efficacy
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psnet.ahrq.gov/node/72582/psn-pdf
December 16, 2020 - Deficiencies in the Veterans Crisis Line Response to a
Veteran Caller Who Died.
December 16, 2020
Washington, DC: Department of Veterans Affairs, Office of Inspector General; November 17, 2020. Report
No 19-08542-11.
https://psnet.ahrq.gov/issue/deficiencies-veterans-crisis-line-response-veteran-caller-who-died
I…
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psnet.ahrq.gov/node/865655/psn-pdf
April 24, 2024 - In patients at risk for compartment syndrome, maintain a high index of suspicion and perform serial
assessments
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psnet.ahrq.gov/node/49853/psn-pdf
February 01, 2019 - Adverse Event During Intrahospital Transport
February 1, 2019
Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
The Case
A 4-year-old boy underwent surgery under general anesthesia for correction o…