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psnet.ahrq.gov/issue/addressing-opioid-crisis-united-states
November 18, 2011 - Book/Report
Addressing the Opioid Crisis in the United States.
Citation Text:
Addressing the Opioid Crisis in the United States. Martin L, Laderman M, Hyatt J, Krueger J. Cambridge, MA: Institute for Healthcare Improvement; April 2016.
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psnet.ahrq.gov/issue/care-compare
May 26, 2021 - Multi-use Website
Care Compare.
Citation Text:
Care Compare. Centers for Medicare and Medicaid Services.
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psnet.ahrq.gov/issue/pharmacy-mixes-prescriptions
March 10, 2021 - Commentary
Pharmacy mixes up prescriptions.
Citation Text:
Brushwood DB. Pharmacy error leads to fatal medication mix-up. Pharmacy Today. 2017;23(12):42. doi:10.1016/j.ptdy.2017.11.012.
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DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/issue/ihi-global-trigger-tool-measuring-adverse-events-2nd-edition
January 09, 2019 - Measurement Tool/Indicator
Classic
IHI Global Trigger Tool for Measuring Adverse Events. 2nd Edition.
Citation Text:
IHI Global Trigger Tool for Measuring Adverse Events. 2nd Edition. Griffin FA, Resar RK. IHI Innovation Series white paper. Cambridge, MA: Instit…
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psnet.ahrq.gov/issue/keeping-commitment-progress-report-four-early-leaders-patient-safety-improvement
October 07, 2008 - Book/Report
Keeping the Commitment: A Progress Report on Four Early Leaders in Patient Safety Improvement.
Citation Text:
Keeping the Commitment: A Progress Report on Four Early Leaders in Patient Safety Improvement. McCarthy D, Klein S. New York, NY: The Commonwealth Fund; March 15,…
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psnet.ahrq.gov/issue/safer-together-survey-advancing-patient-and-workforce-safety
July 12, 2017 - Press Release/Announcement
Safer Together Survey: Advancing Patient and Workforce Safety
Citation Text:
Safer Together Survey: Advancing Patient and Workforce Safety Cambridge, MA: Institute for Healthcare Improvement: January 2023.
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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/improving-nursing-unit-teamwork
January 18, 2011 - Commentary
Improving nursing unit teamwork.
Citation Text:
Kalisch BJ, Begeny SM. Improving nursing unit teamwork. J Nurs Adm. 2005;35(12):550-556. doi:10.1097/00005110-200512000-00009.
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psnet.ahrq.gov/perspective/special-edition-perspective-technology-responses-covid-19
August 31, 2020 - Special Edition Perspective: Technology Responses to COVID-19
July 21, 2020
View more articles from the same authors.
Citation Text:
Marcin JP, Cohen NM, Lowery C, et al. Special Edition Perspective: Technology Responses to COVID-19. PSNet [internet]. Rockville (M…
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psnet.ahrq.gov/node/50699/psn-pdf
November 26, 2019 - Patient Safety in Frail Older Patients
November 26, 2019
Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
Background
Older patients are at a particular risk of experiencing a patient safety event. Stud…
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psnet.ahrq.gov/node/33780/psn-pdf
July 01, 2015 - Safety and Medical Education
January 1, 2014
Ranji SR. Safety and Medical Education. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/safety-and-medical-education
Annual Perspective 2014
As the patient safety field has grown, so too has the appreciation for the need to improve safety in medical
educatio…
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psnet.ahrq.gov/primer/duty-hours-and-patient-safety
June 15, 2024 - Duty Hours and Patient Safety
Citation Text:
Duty Hours and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/60242/psn-pdf
March 01, 2021 - full-time
equivalent nurse practitioners and social workers (i.e., each support team can handle 100 cases
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psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
February 26, 2025 - able to identify those situations and work on figuring out exactly what is going on when there are cases
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psnet.ahrq.gov/perspective/are-we-safer-today
February 26, 2025 - able to identify those situations and work on figuring out exactly what is going on when there are cases
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psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system
January 01, 2008 - November 21, 2021
WebM&M Cases
Two Pills, Same Drug
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psnet.ahrq.gov/perspective/conversation-reed-v-tuckson-md
September 01, 2016 - doing stroke management today in many of these telehealth centers are seeing orders of magnitude more cases … One concerning study reviewed 32 cases that ended in catastrophic outcomes, including deaths and malpractice
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psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
May 01, 2007 - the British Ministry of Health set up a committee that initiated confidential investigations of 5800 cases … 1970s and 1980s, the realization that clinical problems underlie much litigation, certain high-profile cases
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psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-pharmacists-perspective
June 01, 2016 - HRO) Principles and Patient Safety
February 26, 2025
Role of remediation in cases
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psnet.ahrq.gov/node/73128/psn-pdf
July 01, 2022 - Hospital at Home? Care Reduces Costs, Readmissions,
and Complications and Enhances Satisfaction for Elderly
Patients.
April 7, 2021
https://psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-
and-enhances
Summary
The Hospital at Homesm program provides hospital-level care…