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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33675/psn-pdf
    October 01, 2008 - Identifying Adverse Events Not Present on Admission: Can We Do It? October 1, 2008 Naessens JM. Identifying Adverse Events Not Present on Admission: Can We Do It? PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it Perspective Interest is growi…

  2. Pharmacist Role in Patient Safety | PSNet

    psnet.ahrq.gov/perspective/pharmacist-role-patient-safety
    June 29, 2020 - Annual Perspective Pharmacist Role in Patient Safety February 21, 2020  View more articles from the same authors. Citation Text: Dopp AL, Hall KK. Pharmacist Role in Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…

  3. Discharge Planning and Transitions of Care | PSNet

    psnet.ahrq.gov/primer/discharge-planning-and-transitions-care
    June 15, 2024 - Discharge Planning and Transitions of Care Citation Text: Bajorek SA, McElroy V. Discharge Planning and Transitions of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibT…

  4. Diagnostic Failure: The Growing Deficit | PSNet

    psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
    June 01, 2005 - Diagnostic Failure: The Growing Deficit Citation Text: Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNo…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33720/psn-pdf
    November 01, 2011 - Current research is trying to capture in real time and diagnose in real time what teams and individuals

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33742/psn-pdf
    December 01, 2012 - use because there is no way from administrative databases or just from medical records that we can capture

  7. Despite Clues, Failed to Rescue | PSNet

    psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
    August 02, 2015 - describe outcomes specific to a very narrow window of the acute care episode.( 14-16 ) They do not capture

  8. In Conversation With… Rebecca Lawton, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd
    March 24, 2025 - There are some occasions where you capture issues that need to be fed back to the team immediately.

  9. Improving Diagnostic Safety and Quality | PSNet

    psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
    January 31, 2024 - interventions that span contexts, from individual clinician training to organizational strategies to capture

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848107/psn-pdf
    April 26, 2023 - interventions that span contexts, from individual clinician training to organizational strategies to capture

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36911/psn-pdf
    September 01, 2011 - Managing clinical failure: a complex adaptive system perspective. September 1, 2011 Matthews JI, Thomas PT. Managing clinical failure: a complex adaptive system perspective. Int J Health Care Qual Assur. 2007;20(3):184-194. doi:10.1108/09526860710743336. https://psnet.ahrq.gov/issue/managing-clinical-failure-compl…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40908/psn-pdf
    December 08, 2011 - Patients' identification and reporting of unsafe events at six hospitals in Japan. December 8, 2011 Hasegawa T, Fujita S, Seto K, et al. Patients' identification and reporting of unsafe events at six hospitals in Japan. Jt Comm J Qual Patient Saf. 2011;37(11):502-508. https://psnet.ahrq.gov/issue/patients-identifi…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39725/psn-pdf
    August 11, 2010 - The Invisible Gorilla: and Other Ways Our Intuitions Deceive Us. August 11, 2010 Chabris C, Simons D. New York, NY: Crown Publishing Group; 2010. ISBN: 0307459659. https://psnet.ahrq.gov/issue/invisible-gorilla-and-other-ways-our-intuitions-deceive-us This book explores inattentional blindness, as demonstrated in …

  14. Over-the-Counter Oversight | PSNet

    psnet.ahrq.gov/web-mm/over-counter-oversight
    March 21, 2009 - Over-the-Counter Oversight Citation Text: Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72618/psn-pdf
    December 23, 2020 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care December 23, 2020 https://psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards- medical-decisions Summary Nudges are a change in the way choices ar…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49440/psn-pdf
    March 01, 2004 - Autopsy Revelation March 1, 2004 Shojania KG. Autopsy Revelation. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/autopsy-revelation The Case A 45-year-old male with development delay presented to the emergency department with acute abdominal pain. His mother, who was his main caregiver, accompanied him. Th…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34790/psn-pdf
    December 23, 2008 - Cognitive errors in diagnosis: instantiation, classification, and consequences. December 23, 2008 Kassirer JP, Kopelman RI. Cognitive errors in diagnosis: instantiation, classification, and consequences. Am J Med. 1989;86(4):433-41. https://psnet.ahrq.gov/issue/cognitive-errors-diagnosis-instantiation-classificati…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34954/psn-pdf
    June 23, 2009 - Active surveillance of vaccine safety: a system to detect early signs of adverse events. June 23, 2009 Davis RL, Kolczak M, Lewis E, et al. Active surveillance of vaccine safety: a system to detect early signs of adverse events. Epidemiology. 2005;16(3):336-41. https://psnet.ahrq.gov/issue/active-surveillance-vacc…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34805/psn-pdf
    November 07, 2017 - Medication errors in neonatal and paediatric intensive- care units. November 7, 2017 Raju TN, Kecskes S, Thornton JP, et al. Medication errors in neonatal and paediatric intensive-care units. Lancet. 1989;2(8659):374-6. https://psnet.ahrq.gov/issue/medication-errors-neonatal-and-paediatric-intensive-care-units Th…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36671/psn-pdf
    January 18, 2011 - Increasing vigilance on the medical/surgical floor to improve patient safety. January 18, 2011 Jacobs JL, Apatov N, Glei M. Increasing vigilance on the medical/surgical floor to improve patient safety. J Adv Nurs. 2007;57(5). doi:10.1111/j.1365-2648.2006.04161.x. https://psnet.ahrq.gov/issue/increasing-vigilance-m…
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