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  1. Towards an organization with a memory: exploring the organizational generation of adverse events in health care. | PSNet

    psnet.ahrq.gov/issue/towards-organization-memory-exploring-organizational-generation-adverse-events-health-care
    February 22, 2010 - Commentary Towards an organization with a memory: exploring the organizational generation of adverse events in health care. Citation Text: Smith D, Toft B. Towards an organization with a memory: exploring the organizational generation of adverse events in health care. Health Serv Manag…

  2. Patient safety in obstetrics and obstetric anesthesia. | PSNet

    psnet.ahrq.gov/issue/patient-safety-obstetrics-and-obstetric-anesthesia
    August 04, 2021 - Review Patient safety in obstetrics and obstetric anesthesia. Citation Text: Kung A, Pratt SD. Patient safety in obstetrics and obstetric anesthesia. Int Anesthesiol Clin. 2014;52(2):86-110. doi:10.1097/AIA.0000000000000017. Copy Citation Format: DOI Google Scholar PubMed B…

  3. Impact of the Care Quality Commission on Provider Performance: Room for Improvement? | PSNet

    psnet.ahrq.gov/issue/impact-care-quality-commission-provider-performance-room-improvement
    November 18, 2015 - Book/Report Impact of the Care Quality Commission on Provider Performance: Room for Improvement? Citation Text: Impact of the Care Quality Commission on Provider Performance: Room for Improvement? Smithson R, Richardson E, Roberts J, et al. The King's Fund, Alliance Manchester Business S…

  4. Using fault trees to advance understanding of diagnostic errors. | PSNet

    psnet.ahrq.gov/issue/using-fault-trees-advance-understanding-diagnostic-errors
    November 11, 2020 - Commentary Using fault trees to advance understanding of diagnostic errors. Citation Text: Rogith D, Iyengar S, Singh H. Using Fault Trees to Advance Understanding of Diagnostic Errors. Jt Comm J Qual Patient Saf. 2017;43(11):598-605. doi:10.1016/j.jcjq.2017.06.007. Copy Citation F…

  5. Using "near misses" analysis to prevent wrong-site surgery. | PSNet

    psnet.ahrq.gov/issue/using-near-misses-analysis-prevent-wrong-site-surgery
    April 24, 2018 - Study Using "near misses" analysis to prevent wrong-site surgery. Citation Text: Yoon RS, Alaia MJ, Hutzler LH, et al. Using "near misses" analysis to prevent wrong-site surgery. J Healthc Qual. 2015;37(2):126-32. doi:10.1111/jhq.12037. Copy Citation Format: DOI Google Scho…

  6. The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives. | PSNet

    psnet.ahrq.gov/issue/vha-new-england-medication-error-prevention-initiative-model-long-term-improvement
    January 04, 2017 - Commentary The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives. Citation Text: Lesar TS, Anderson ER, Fields J, et al. The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives…

  7. Development and implementation of a pediatric patient safety program. | PSNet

    psnet.ahrq.gov/issue/development-and-implementation-pediatric-patient-safety-program
    September 27, 2010 - Commentary Development and implementation of a pediatric patient safety program. Citation Text: Alton M, Frush K, Brandon D, et al. DEVELOPMENT AND IMPLEMENTATION OF A PEDIATRIC PATIENT SAFETY PROGRAM. Adv Neonatal Care. 2006;6(3):104-111. doi:10.1016/j.adnc.2006.02.003. Copy Citatio…

  8. Safety huddles in the PACU: when a patient self-medicates. | PSNet

    psnet.ahrq.gov/issue/safety-huddles-pacu-when-patient-self-medicates
    December 14, 2016 - Commentary Safety huddles in the PACU: when a patient self-medicates. Citation Text: Setaro J, Connolly M. Safety huddles in the PACU: when a patient self-medicates. J Perianesth Nurs. 2011;26(2):96-102. doi:10.1016/j.jopan.2011.01.010. Copy Citation Format: DOI Google Sc…

  9. Accreditation and Regulation: Can They Help Improve Patient Safety? | PSNet

    psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
    April 01, 2009 - Accreditation and Regulation: Can They Help Improve Patient Safety? Rebecca N. Warburton, PhD | April 1, 2009  Also Read a Conversation View more articles from the same authors. Citation Text: Warburton RN. Accreditation and Regulation: Can They Help Improve Pat…

  10. The Role of Community Pharmacists in Patient Safety | PSNet

    psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety
    October 24, 2021 - The Role of Community Pharmacists in Patient Safety October 24, 2021  Also Read the Conversation View more articles from the same authors. Citation Text: Luchen GG, Hall KK, Hough KR. The Role of Community Pharmacists in Patient Safety . PSNet [internet]. Rockv…

  11. Medication Safety in Nursing Homes: What's Wrong and How to Fix It | PSNet

    psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it
    August 01, 2012 - Medication Safety in Nursing Homes: What's Wrong and How to Fix It Jerry Gurwitz, MD | August 1, 2012  Also Read a Conversation View more articles from the same authors. Citation Text: Gurwitz JH. Medication Safety in Nursing Homes: What's Wrong and How to Fix I…

  12. EHR Copy and Paste and Patient Safety | PSNet

    psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
    January 01, 2018 - EHR Copy and Paste and Patient Safety Shannon M. Dean, MD | January 1, 2018  Also Read a Conversation View more articles from the same authors. Citation Text: Dean SM. EHR Copy and Paste and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841468/psn-pdf
    December 14, 2022 - Don’t Bite Your Tongue. December 14, 2022 Singh NS. Don’t Bite Your Tongue. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/dont-bite-your-tongue The Case A 63-year-old woman with a past medical history of hypertension, osteoarthritis, migraine headaches, and daily smoking was admitted to a hospital for ant…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33631/psn-pdf
    April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety April 1, 2006 Alldredge BK, Koda-Kimble MA. Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacis…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33850/psn-pdf
    January 01, 2018 - EHR Copy and Paste and Patient Safety January 1, 2018 Dean SM. EHR Copy and Paste and Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety Perspective Although the ability to copy and paste text is a central benefit of computing in general, and electronic…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33868/psn-pdf
    October 01, 2018 - Safety in the Retail Pharmacy October 1, 2018 Chui MA. Safety in the Retail Pharmacy. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/safety-retail-pharmacy Perspective There are approximately 67,000 retail/community pharmacies dispensing 4.4 billion prescriptions each year.(1) Many patients interact w…

  17. Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx Spotlight When the Lytes Go Out: A Case of Inpatient Cardiac Arrest Source and Credits • This presentation is based on the September 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psne…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33747/psn-pdf
    March 01, 2013 - The Literature on Health Care Simulation Education: What Does It Show? March 1, 2013 Cook DA. The Literature on Health Care Simulation Education: What Does It Show? PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/literature-health-care-simulation-education-what-does-it-show Perspective The education o…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866847/psn-pdf
    September 25, 2024 - In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement September 25, 2024 Stockmeier CA, Mossburg S, Lee M. In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Are…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49730/psn-pdf
    April 01, 2015 - Transition to Nowhere April 1, 2015 Farrell TW. Transition to Nowhere. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/transition-nowhere The Case A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension, and chronic kidney disease was admitted to the hospital …
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