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psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
February 26, 2025 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer
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July 31, 2023
Innovation
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psnet.ahrq.gov/node/851389/psn-pdf
July 31, 2023 - Ambulatory Safety Nets to Reduce Missed and Delayed
Diagnoses of Cancer
July 31, 2023
https://psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
Summary
Concern over patient safety issues associated with inadequate tracking of test results has grown over the
last decade, a…
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psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
May 16, 2022 - the Emergency Medical Services Trigger Tool (EMSTT), for use in ground-based EMS settings to identify cases … team found that, compared with a random sampling strategy, the EMSTT was more accurate at identifying cases … Trigger tools can be used to evaluate low-risk, high-frequency cases that are not typically reviewed
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psnet.ahrq.gov/node/855058/psn-pdf
October 31, 2023 - In some cases, it’s hard to discern if the
reporting is true, if the incidence of workplace violence … But in some cases, these techniques are not enough.
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psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd
October 01, 2007 - In some cases the corner is not the right one to be cut, so it's called at-risk behavior. … You have to support noncompliance in some cases.
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psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
January 31, 2020 - may be better than AI, but is AI better than the general radiologist in a rural facility reading 250 cases … 29, 2020
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psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-improve-safety
November 01, 2017 - patients who could benefit the most, and many of the apps are not safe or secure.( 15 ) Finally, in some cases … December 15, 2021
WebM&M Cases
A Mistaken Dose of Naloxone
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psnet.ahrq.gov/issue/beyond-organisational-accident-need-error-wisdom-frontline
November 18, 2015 - Commentary
Beyond the organisational accident: the need for "error wisdom" on the frontline.
Citation Text:
Reason J. Beyond the organisational accident: the need for "error wisdom" on the frontline. Qual Saf Health Care. 2004;13 Suppl 2:ii28-33.
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psnet.ahrq.gov/issue/medical-error-second-victim-0
February 17, 2017 - Commentary
Medical error: the second victim.
Citation Text:
McCay L, Wu AW. Medical error: the second victim. Br J Hosp Med (Lond). 2012;73(10):C146-148.
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Do…
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psnet.ahrq.gov/issue/integration-formalized-handoff-system-surgical-curriculum-resident-perspectives-and-early
May 25, 2016 - Study
Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results.
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Telem DA. Integration of a Formalized Handoff System Into the Surgical Curriculum. Archives of Surgery. 2011;146(1). doi:10.1001/archsurg.2010.294.
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psnet.ahrq.gov/issue/documenting-day-discussion-ahead-crest-wave-creating-national-agenda-systemic-change-enhanced
April 28, 2021 - Book/Report
Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change for Enhanced Clinician Well-Being.
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Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change …
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psnet.ahrq.gov/issue/junior-doctors-shifts-and-sleep-deprivation
October 16, 2012 - Commentary
Junior doctors' shifts and sleep deprivation.
Citation Text:
Murray A, Pounder R, Mather H, et al. Junior doctors' shifts and sleep deprivation. BMJ. 2005;330(7505):1404.
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psnet.ahrq.gov/issue/essential-guide-patient-safety-officers-second-edition
February 15, 2017 - Book/Report
The Essential Guide for Patient Safety Officers, Second Edition.
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The Essential Guide for Patient Safety Officers, Second Edition. Leonard M, Frankel A, Federico F, et al, eds. Oakbrook Terrace, IL: Joint Commission Resources, Institute for Healthcare Improv…
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psnet.ahrq.gov/issue/effects-work-shift-or-shift-length-radiation-safety-perception
August 23, 2023 - Study
Effects of work shift or shift length on radiation safety perception.
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Effects of work shift or shift length on radiation safety perception. Moore QT, Bruno MA. Radiol Technol. 2023;94(6):409-418.
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psnet.ahrq.gov/issue/condition-concern-innovative-response-system-enhancing-hospitalized-patient-care-and-safety
April 24, 2018 - Commentary
Condition concern: an innovative response system for enhancing hospitalized patient care and safety.
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Baird SK, Turbin LB. Condition concern: an innovative response system for enhancing hospitalized patient care and safety. J Nurs Care Qual. 2011;26(3):199-207. d…
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psnet.ahrq.gov/issue/no-excuses-reality-demands-action
July 20, 2022 - Meeting/Conference Proceedings
No excuses: the reality that demands action.
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Denham CR, Bagian JP, Daley J, et al. No Excuses: The Reality That Demands Action. doi:10.1097/01.jps.0000183854.29928.4d.
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psnet.ahrq.gov/issue/using-ismp-medication-safety-self-assessment-improve-medication-use-processes
January 05, 2017 - Study
Using the ISMP Medication Safety Self-Assessment to improve medication use processes.
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Lesar TS, Mattis A, Anderson E, et al. Using the ISMP Medication Safety Self-Assessment to improve medication use processes. Jt Comm J Qual Saf. 2003;29(5):211-26.
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psnet.ahrq.gov/issue/clinical-risk-management-enhancing-patient-safety-2nd-ed
May 20, 2019 - Book/Report
Classic
Clinical Risk Management. Enhancing Patient Safety. 2nd ed.
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Clinical Risk Management. Enhancing Patient Safety. 2nd ed. Vincent CA, ed. London, UK: BMJ Books; 2001. ISBN: 9780727913920.
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psnet.ahrq.gov/issue/guide-patient-and-family-engagement-environmental-scan-report
August 01, 2012 - Book/Report
Guide to Patient and Family Engagement: Environmental Scan Report.
Citation Text:
Guide to Patient and Family Engagement: Environmental Scan Report. Maurer M, Dardess P, Carman KL, Frazier K, Smeeding L. Rockville, MD: Agency for Healthcare Research and Quality; May 2012. AHR…
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psnet.ahrq.gov/issue/crew-resource-management-applications-healthcare-organizations
November 10, 2021 - Commentary
Crew resource management: applications in healthcare organizations.
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Oriol MD. Crew resource management: applications in healthcare organizations. J Nurs Adm. 2006;36(9):402-406.
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