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1761. Establishing a Safety Culture: Thinking Small | PSNet
      psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
      December 01, 2006 - Establishing a Safety Culture: Thinking Small Timothy J. Hoff, PhD | December 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. Rockville (MD): Age…

1762. In Conversation With… Christopher P. Landrigan, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-christopher-p-landrigan-md-mph
      April 01, 2013 - In Conversation With… Christopher P. Landrigan, MD, MPH April 1, 2013  Also Read an Essay Citation Text: In Conversation With… Christopher P. Landrigan, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …

1763. Are Residency Duty Hour Rules Improving Patient Safety? | PSNet
      psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
      April 01, 2013 - Are Residency Duty Hour Rules Improving Patient Safety? Kathlyn E. Fletcher, MD, MA; Darcy A. Reed, MD, MPH | April 1, 2013  Also Read a Conversation View more articles from the same authors. Citation Text: Fletcher KE, Reed DA. Are Residency Duty Hour Rules Imp…

1764. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-12/spotlight_case_csf_leak_after_elective_spine_surgery_slides_-_final.pptx
      January 01, 2024 - Spotlight Spotlight Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis 1 Source and Credits This presentation is based on the December 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Comment…

1765. In Conversation With… Harlan Krumholz, MD, SM | PSNet
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      April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM April 1, 2018  Also Read an Essay Citation Text: In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

1766. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication | PSNet
      psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
      August 01, 2012 - SPOTLIGHT CASE The Risks of a Malpositioned Gastrostomy Tube and Poor Communication Citation Text: Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…

1767. In Conversation With… Didier Pittet, MD, MS | PSNet
      psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
      May 01, 2014 - In Conversation With… Didier Pittet, MD, MS May 1, 2014  Also Read an Essay Citation Text: In Conversation With… Didier Pittet, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. …

1768. Patient Safety During Hospital Discharge | PSNet
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      April 01, 2018 - Patient Safety During Hospital Discharge Katherine Liang and Eric Alper, MD | April 1, 2018  Also Read a Conversation View more articles from the same authors. Citation Text: Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. Rockville…

1769. Glossary | PSNet
      psnet.ahrq.gov/glossary
      January 01, 2003 - Glossary A B C D E F H I J L M N O P R S T U V W Active Error (or Active Failure) The terms active and latent as applied to errors were coined by Reason . Active errors occur at the point of contact between a human and some aspect of a larger system (e.g., a human–machine in…

1770. Glossary | PSNet
      psnet.ahrq.gov/glossary-0
      January 01, 2003 - Glossary   Definitions abound in the medical error and patient safety literature, with subtle and not-so-subtle variations in the meanings of important terms. An effort was made to adopt the most straightforward terminology, with definitions that enjoy the widest use. A B C D E F H I J L M N O P R S T U…

1771. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis | PSNet
      psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
      March 09, 2022 - SPOTLIGHT CASE Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis Citation Text: Castillo JA, Price R, Kim KD. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis. PSNet [internet]. …

1772. Innovations in Promoting Hand Hygiene Compliance | PSNet
      psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
      May 01, 2014 - Innovations in Promoting Hand Hygiene Compliance Alexandre R. Marra, MD and Michael B. Edmond, MD, MPH, MPA | May 1, 2014  Also Read a Conversation View more articles from the same authors. Citation Text: Marra AR, Edmond MB. Innovations in Promoting Hand Hygie…

1773. Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges | PSNet
      psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workforce-challenges
      August 30, 2023 - Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges Kathleen Sanford DBA, RN, FAAN, FACHE; Sue Schuelke PhD, RN-BC, CNE, CCRN-K; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | August 30, 2023  Also Read the Conversation View more articles from the…

1774. In Conversation with... Kathleen Sanford and Sue Schuelke about Virtual Nursing | PSNet
      psnet.ahrq.gov/perspective/conversation-kathleen-sanford-and-sue-schuelke-about-virtual-nursing
      August 30, 2023 - In Conversation with... Kathleen Sanford and Sue Schuelke about Virtual Nursing Kathleen Sanford DBA, RN, FAAN, FACHE; Sue Schuelke PhD, RN-BC, CNE, CCRN-K; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | August 30, 2023  Also Read the Essay View more articles from the …

1775. In Conversation with... Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
      August 30, 2023 - In Conversation with... Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD | August 30, 2023  Also Read the Essay View more articles from the same authors. …

1776. Beyond the Pandemic: Creating Total Systems Safety | PSNet
      psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
      August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD | August 30, 2023  Also Read the Conversation View more articles from the same authors. Citation Text: Van CM, Mossb…

1777. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867429/psn-pdf
      December 18, 2024 - Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis December 18, 2024 Castillo JA, Price R, Kim KD. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis. PSNet [internet]. 2024. https://psnet.ahrq.gov/w…

1778. Artificial Intelligence and Patient Safety: Promise and Challenges | PSNet
      psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
      March 27, 2024 - Artificial Intelligence and Patient Safety: Promise and Challenges Patrick Tighe, MD, MS; Bryan M. Gale, MA; Sarah E. Mossburg, RN, PhD | March 27, 2024  Also Read the Conversation View more articles from the same authors. Citation Text: Tighe P, Mossburg S, Gal…

1779. In Conversation with...Patrick Tighe about Artificial Intelligence | PSNet
      psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
      March 27, 2024 - In Conversation with...Patrick Tighe about Artificial Intelligence Patrick Tighe, MD, MS | March 27, 2024  Also Read the Essay View more articles from the same authors. Citation Text: Tighe P. In Conversation with..Patrick Tighe about Artificial Intelligence …