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psnet.ahrq.gov/web-mm/communication-error-closed-icu
July 01, 2016 - Conversely, a rigid approach to the closed model of care acts as a barrier to communication.
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psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
August 05, 2022 - Duplicate Therapies in Retail Pharmacy
Citation Text:
Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/primer/nursing-and-patient-safety
September 15, 2024 - themes are encompassed within an understanding of human factors, which can either facilitate, or be a barrier
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psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms
December 07, 2020 - Another big barrier is that dentists, in general, do not have access to your healthcare data.
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psnet.ahrq.gov/web-mm/check-wristband
August 03, 2009 - Recognizing and overcoming inadequate health literacy, a barrier to care.
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psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
November 26, 2014 - History
March 21, 2009
WebM&M Cases
Language Barrier
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psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
May 11, 2019 - The first barrier to communication-related harm is the radiologist’s report.
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psnet.ahrq.gov/node/867985/psn-pdf
January 01, 2025 - Suicide Prevention
March 25, 2025
Boudreaux E, Gale B, Mossburg SE. Suicide Prevention. PSNet [internet]. 20024.
https://psnet.ahrq.gov/perspective/suicide-prevention
Introduction
Suicide is one of the leading causes of death in the United States, accounting for nearly 50,000 deaths in
2022, a 36% rise since 2000…
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psnet.ahrq.gov/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance
Lance L. Roberts, MS; Marcia M. Ward, PhD; Thomas C. Evans, MD | April 1, 2010
Also Read a Conversation
View more articles from the same authors.
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psnet.ahrq.gov/node/46135/psn-pdf
July 11, 2017 - Two-state collaborative study of a multifaceted
intervention to decrease ventilator-associated events.
July 11, 2017
Rawat N, Yang T, Ali KJ, et al. Two-State Collaborative Study of a Multifaceted Intervention to Decrease
Ventilator-Associated Events. Crit Care Med. 2017;45(7):1208-1215.
doi:10.1097/CCM.0000000000…
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psnet.ahrq.gov/perspective/antibiotic-and-opioid-stewardship-dentistry
December 07, 2020 - Another big barrier is that dentists, in general, do not have access to your healthcare data.
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psnet.ahrq.gov/web-mm/dangerous-shift
July 24, 2013 - human desire to "ensure that this never happens again" following an unfortunate outcome can serve as a barrier
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psnet.ahrq.gov/web-mm/case-mistaken-intubation
July 01, 2016 - The biggest barrier to exchanging information across institutions is not so much technology as it is
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psnet.ahrq.gov/issue/engaging-patients-improving-ambulatory-care
January 17, 2024 - Book/Report
Engaging Patients in Improving Ambulatory Care.
Citation Text:
Engaging Patients in Improving Ambulatory Care. Aligning Forces for Quality. Princeton, NJ: Robert Wood Johnson Foundation; 2013.
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psnet.ahrq.gov/issue/resilient-actions-diagnostic-process-and-system-performance
November 13, 2024 - Study
Resilient actions in the diagnostic process and system performance.
Citation Text:
Smith MW, Giardina TD, Murphy DR, et al. Resilient actions in the diagnostic process and system performance. BMJ Qual Saf. 2013;22(12):1006-13. doi:10.1136/bmjqs-2012-001661.
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psnet.ahrq.gov/node/866841/psn-pdf
September 23, 2024 - System Approaches to Social Determinants of Health
Screening and Intervention Innovation Summary
September 23, 2024
https://psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and-
intervention-innovation
Summary
UNC Health is a nonprofit healthcare system of more than 500 clinics and…
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psnet.ahrq.gov/issue/using-machine-learning-improve-patient-safety-home-or-remote-setting-adults
May 25, 2022 - Book/Report
Using Machine Learning to Improve Patient Safety in the Home or Remote Setting for Adults.
Citation Text:
Using Machine Learning to Improve Patient Safety in the Home or Remote Setting for Adults. Feske-Kirby K, Whittington J, McGaffigan P. Boston, MA: Institute for Healthcar…
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psnet.ahrq.gov/issue/safety-medication-use
January 01, 2019 - Book/Report
Safety in Medication Use.
Citation Text:
Safety in Medication Use. Tully MP, Franklin BD, eds. Boca Raton, FL: CRC Press, Taylor and Francis Group; 2016. ISBN: 9781482227000.
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psnet.ahrq.gov/issue/complications-acknowledging-managing-and-coping-human-error
March 13, 2024 - Review
Complications: acknowledging, managing, and coping with human error.
Citation Text:
Helo S, Moulton C-AE. Complications: acknowledging, managing, and coping with human error. Transl Androl Urol. 2017;6(4):773-782. doi:10.21037/tau.2017.06.28.
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psnet.ahrq.gov/issue/eliminating-unintentionally-retained-surgical-items-special-report
December 07, 2022 - Special or Theme Issue
Eliminating Unintentionally Retained Surgical Items - Special Report.
Citation Text:
Eliminating Unintentionally Retained Surgical Items - Special Report. Saver C. AORN J. 2022;116(2):111-132.
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